OMB Control No. 2900-0576
Respondent Burden: 3 Minutes
Expiration Date: 7/31/2017
CERTIFICATE OF AFFIRMATION OF ENROLLMENT
AGREEMENT - CORRESPONDENCE COURSE
1. FIRST NAME-MIDDLE INITIAL-LAST NAME OF ELIGIBLE PERSON
2. VA FILE NO.
3. NAME OF COURSE
5. NAME AND ADDRESS OF SCHOOL
4. DATE ENROLLMENT
AGREEMENT SIGNED
PURPOSE OF THE AFFIRMATION PROVISION OF LAW
To provide you time (no less than five full days following your signing of an enrollment agreement) during which you can
reflect on your decision to enroll in a correspondence course and determine if such correspondence course is suitable to
your abilities and interests. The Correspondence School Agreement you have signed is not effective unless you complete
this form and return it to the school.
AFFIRMATION PROCEDURE:
A. Decision not to Affirm - If you decide not to affirm the Correspondence School Agreement you have signed, do not
sign this form. Destroy it. Additionally, you may notify the institution, at any time, of your decision not to affirm the
enrollment agreement. The institution, thereupon, without imposing any penalty or fee, shall make full refund of all
amounts paid.
B. Decision to Affirm - If you decide to affirm the Correspondence School Agreement you have signed, you may affirm
only after the expiration of 5 full days after the day on which the agreement was signed. For example, if the contract was
signed on the 1st day of a month, you must sign and date this affirmation certification form on or after the 7th day.
VA WILL NOT ACCEPT ANY AFFIRMATION YOU SIGN BEFORE THE 7TH DAY.
VA WILL NOT PAY FOR LESSONS THAT YOU COMPLETE AND THE SCHOOL SERVICES BEFORE
THE PROPER AFFIRMATION DATE.
TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:
I have read and I understand the enrollment agreement that I entered into with the above named school on the date
indicated in Item 4. By signing this form, I affirm such enrollment agreement and certify, under penalty of law, that I have
not signed this affirmation certificate until after the expiration of 5 full days after the date I signed the aforesaid
enrollment agreement.
(SUBMIT WITH ENROLLMENT CERTIFICATION)
INSTRUCTION TO CLAIMANT: After completion of Items 6 and 7 on or after the 7th day, return VA COPY 1 and
SCHOOL COPY 2 of this form to the school identified in Item 5.
INSTRUCTION TO SCHOOL: Once the student submits VA COPY 1 and SCHOOL COPY 2 of VA Form 22-1999c to
your facility, the school should submit VA COPY 1 of VA Form 22-1999c (Certificate of Affirmation of Enrollment
Agreement - Correspondence Course) and VA Form 22-1999 (Enrollment Certification) to the Department of Veterans
Affairs.
6. DATE SIGNED
7. SIGNATURE OF ELIGIBLE PERSON
VA FORM
22-1999c
SUPERSEDES VA FORM 22-1999c, NOV 2008,
JUL 2014
WHICH WILL NOT BE USED.
1
2
