Va Form 22-5495 - Dependents' Request For Change Of Program Or Place Of Training
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4OMB Approved No. 2900-0099
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
DEPENDENTS' REQUEST FOR CHANGE OF PROGRAM
OR PLACE OF TRAINING
(Under Provisions of Chapters 33 and 35, Title 38, U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at
PART I - APPLICANT INFORMATION
(First, Middle Initial, Last)
VA DATE STAMP
1. NAME
(For VA Use Only)
3. VA FILE NUMBER
2. SOCIAL SECURITY NUMBER
4. SEX OF APPLICANT
5. DATE OF BIRTH
MALE
FEMALE
(Number and street or rural route, city or P.O., State and 9 DIGIT ZIP Code)
6. CURRENT MAILING ADDRESS
(Include Area Code)
7. TELEPHONE NUMBER(S)
PRIMARY
SECONDARY
(If applicable)
8. EMAIL ADDRESS
(Complete this item only if you wish to start, change or stop direct deposit) (See Instructions, page 3, Item 9 for more information on Direct Deposit)
9. DIRECT DEPOSIT
NOTE - To prevent possible delays in payment, claimants are encouraged to use Direct Deposit and set up a Electronic Funds Transfer (EFT).
START OR CHANGE DIRECT DEPOSIT (Attach a voided personal check or provide the information requested in Items A thru D below)
STOP EFT
C. 9 DIGIT ROUTING OR TRANSIT NUMBER
D. ACCOUNT NUMBER
A. TYPE OF ACCOUNT
B. NAME OF FINANCIAL INSTITUTION
CHECKING
SAVINGS
10. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
A. NAME
C. TELEPHONE NUMBER
B. ADDRESS
PART II - QUALIFYING INDIVIDUAL INFORMATION
(First, Middle, Last)
11. NAME OF INDIVIDUAL ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED
13. BRANCH OF SERVICE
12. SOCIAL SECURITY NUMBER OR VA FILE NUMBER
14. DATE OF BIRTH
15. DATE OF DEATH OR DATE LISTED AS MIA OR POW
16. IS QUALIFYING INDIVIDUAL CURRENTLY ON ACTIVE DUTY
YES
NO
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL
SPOUSE
SURVIVING SPOUSE
CHILD
STEPCHILD
ADOPTED CHILD
18. DO YOU OR THE QUALIFYING INDIVIDUAL ON WHOSE ACCOUNT YOU ARE CLAIMING BENEFITS HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES
NO
PART III - APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is on active duty)
(If "No," skip to Part IV)
19. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES?
YES
NO
20. INFORMATION ABOUT YOUR PERIODS OF ACTIVE DUTY
A. DATE ENTERED
B. DATE SEPARATED
C. BRANCH OF SERVICE OR RESERVE
D. CHARACTER OF
ACTIVE DUTY
FROM ACTIVE DUTY
OR GUARD COMPONENT
DISCHARGE
VA FORM
22-5495
SUPERSEDES VA FORM 22-5495, SEP 2016,
Page 1
DEC 2016
WHICH WILL NOT BE USED.
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