Va Form 22-1990 - Application For Va Education Benefits Page 7

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SOCIAL SECURITY NUMBER OF APPLICANT

PART VII - INFORMATION ON VA EDUCATION BENEFITS

NOTE: The most current information on VA education benefits is available online at

If you would like to receive a printed pamphlet check here.

PART VIII - MARITAL AND DEPENDENCY STATUS

NOTE: Only complete this section if you have military service before January 1, 1977 (or delayed entry before January 2, 1978). See instructions.

23. ARE YOU MARRIED?

YES

24. DO YOU HAVE ANY CHILDREN WHO ARE UNDER AGE 18, OR OVER 18 BUT UNDER AGE 23, NOT MARRIED AND ATTENDING SCHOOL, OR OF ANY AGE

PERMANENTLY HELPLESS FOR MENTAL OR PHYSICAL REASONS?

YES

25. DO YOU HAVE A PARENT WHO IS DEPENDENT UPON YOU FOR FINANCIAL SUPPORT?

YES

PART IX - REMARKS

(If more space is needed, please attach a separate sheet of paper. Be sure to include your name and social security number on each sheet)

APPLICATION SUBMISSION REMINDERS

Did you remember to ........

• Write your social security number on each page?

• Write your complete mailing address?

• Attach all supporting documents (e.g. voided check, orders, DD214, kicker contract, NOBE, cash collection voucher, etc.)?

IF SO, PLEASE SIGN AND DATE THE APPLICATION BELOW

PART X - CERTIFICATION AND SIGNATURE OF APPLICANT

I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief. If on active duty, I also certify that I

have consulted with an Education Service Officer (ESO) regarding my education program.

PENALTY - Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of

these or other benefits and in criminal penalties.

26A. SIGNATURE OF APPLICANT (DO NOT PRINT)

26B. DATE SIGNED

PAGE 4 OF 4

VA FORM 22-1990, NOV 2014