Va Form 21-674 - Request For Approval Of School Attendance - Department Of Veterans Affairs

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OMB Approved No. 2900-0049

Respondent Burden: 15 minutes

Expiration Date: 03/31/2018

1. ADDRESS OF VA OFFICE

REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE

IMPORTANT - Be sure to read the Instructions on the reverse of Copy 1 before completing this form. The form should be completed in duplicate and signed in Part III.

(Also sign certification in Part III)

PART I - TO BE COMPLETED BY CLAIMANT

(Type or Print)

2A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN

2B. E-Mail ADDRESS OF VETERAN (If

3. VA FILE NUMBER

applicable)

C/CSS

(Veteran's child attending school) (Type or print)

4A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF STUDENT

4B. STUDENT'S SOCIAL SECURITY NUMBER

5B. HAS STUDENT EVER MARRIED?

5A. DATE OF BIRTH

5C. DATE OF MARRIAGE

(If "Yes," complete Item 5C)

YES

(Number and street or rural route, city

7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY

6. ADDRESS OF STUDENT

or P.O., State and Zip Code)

VA DEPENDENTS EDUCATIONAL ASSISTANCE (DEA), THE FEDERAL EMPLOYEE'S

COMPENSATION ACT OR ANY OTHER AGENCY OR PROGRAM OF THE UNITED STATES

GOVERNMENT?

(If "Yes," complete Items 7B and 7C. If "No," skip to Item 8A)

YES

7B. AGENCY NAME

7C. DATE PAYMENTS BEGAN (Month, day, year)

8A. NAME AND ADDRESS OF SCHOOL FOR WHICH APPROVAL IS REQUESTED

8B. NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING

9A. OFFICIAL BEGINNING DATE OF REGULAR TERM OR

9B. DATE STUDENT STARTED OR EXPECTS TO START

9C. EXPECTED DATE OF GRADUATION

COURSE (Month, day, year)

(Month, day, year)

10A. IS STUDENT EN-

10C. NUMBER OF

10D. HOURS

10B. SUBJECT FOR WHICH STUDENT IS ENROLLED

ROLLED IN A FULL-

(If other than full-time high school or college course)

SESSIONS PER WEEK

PER WEEK

TIME HIGH SCHOOL

OR COLLEGE COURSE?

YES

(If "No," complete Items

10B, 10C and 10D)

11A. WAS STUDENT ATTENDING ANY SCHOOL AT END OF

11B. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM

LAST SCHOOL TERM?

(If "Yes," complete Items 11B thru 11F)

YES

11C. NO. OF SESSIONS

11D. HOURS PER WEEK

11F. ENDING DATE OF LAST TERM

11E. BEGINNING DATE OF LAST TERM

PER WEEK

(See instructions on reverse for when required)

PART II - STUDENT'S INCOME AND NET WORTH

12. REPORT OF INCOME BY CALENDAR YEAR (IMPORTANT - Do NOT report VA benefits)

13. VALUE OF ESTATE

C. EXPECTED

B. RECEIVED

A. SAVINGS

(REPORT FOR YEAR IN WHICH SCHOOL

(Report for year following

A. SOURCE

(Including cash)

that shown in Column B)

TERM BEGINS-SEE ITEM 9 ABOVE)

EARNINGS FROM

B. SECURITIES, BONDS,

ALL EMPLOYMENT

ETC.

ANNUAL SOCIAL

C. REAL ESTATE

SECURITY

(Not your home)

OTHER

D. ALL OTHER ASSETS

ANNUITIES

ALL OTHER INCOME

E. TOTAL OF ABOVE

(Interest, dividends, etc.)

14. REMARKS

PART III - CERTIFICATION AND AGREEMENT TO BE SIGNED BY CLAIMANT

NOTE: This part will be completed by the student only if he or she has attained majority and is claiming benefits in his or her own right. Otherwise, the veteran, surviving

spouse, guardian or custodian will sign and also enter his or her relationship to the student.

Receipt by the student of VA Dependents Educational Assistance (DEA), the Federal Employee's Compensation Act, or benefit from another Federal Agency (U.S. Service

Academy, U.S. Merchant Marine Academy, Bureau of Indian Affairs, etc.) with additional compensation payments based on the student's school attendance is considered a

duplication of benefits and is prohibited.

I CERTIFY THAT the information given above is true and correct to the best of my knowledge and belief and request approval of the course of education or training shown above.

I AGREE to notify the Department of Veterans Affairs immediately of any changes in this course of education, transfer to another school, discontinuance of school

attendance, receipt of Dependents Educational Assistance, or marriage prior to completion of the course. I understand that continued entitlement to school attendance may be

based on information I have furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries, receives VA Dependents

Education Assistance (DEA) benefits, leaves school, or passes away.

15A. SIGNATURE

15B. DAYTIME PHONE NO.

15C. EVENING PHONE NO.

16. RELATIONSHIP TO STUDENT

17. DATE

(Include Area Code)

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.

VA FORM

EXISTING STOCKS OF VA FORM 21-674, FEB 2012,

21-674

WILL BE USED.

APR 2015