Va Form 22-1990n - Application For Va Education Benefits Under The National Call To Service (Ncs) Program Page 4

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SOCIAL SECURITY NUMBER OF APPLICANT
PART III - SERVICE INFORMATION
NOTE: It will help VA process your claim if you send the following:
DD 2863 (National Call to Service (NCS) Election of Options)
DD Form 214 (Member 4) for all periods of active duty service
9A. ARE YOU NOW ON ACTIVE DUTY?
YES
NO
9B. ARE YOU NOW ON TERMINAL LEAVE JUST BEFORE DISCHARGE?
(If "Yes,"please provide a copy of your DD Form 214 (Member 4) when issued)
YES
NO
10. PLEASE COMPLETE THE FOLLOWING FOR EACH PERIOD OF MILITARY SERVICE
C. SERVICE COMPONENT (USN, USAF,
D. SERVICE STATUS (Active duty, drilling reservist,
A. DATE ENTERED
B. DATE SEPARATED
USAR, ARNG, ETC.)
IRR, etc.)
PART IV - ENTITLEMENT TO AND USAGE OF ADDITIONAL TYPES OF ASSISTANCE
11A. ARE YOU CURRENTLY PARTICIPATING IN A SENIOR ROTC SCHOLARSHIP PROGRAM
WHICH PAYS FOR YOUR TUITION, FEES, BOOKS AND SUPPLIES UNDER SECTION 2107,
YES
NO
TITLE 10, U.S. CODE?
11B. FOR ACTIVE DUTY CLAIMANTS ONLY: Are you receiving or do you anticipate receiving
any money (including but not limited to Federal Tuition Assistance) from the Armed Forces
or Public Health Service for the course for which you have applied to the VA for education
YES
NO
benefits? If you receive such benefits during any part of your training, check "YES."
11C. FOR CIVILIAN EMPLOYEES OF THE U.S. GOVERNMENT ONLY: Do you expect to receive
funds from your agency or department for the same course(s) for which you expect to receive VA
education assistance? (If "Yes, " show the source of these funds.)
YES
NO
APPLICATION SUBMISSION REMINDERS
Did you remember to .......
Write your complete mailing address?
Attach a copy of DD 2863 (National Call to Service (NCS) Election of Options)
IF SO, PLEASE SIGN AND DATE THE APPLICATION BELOW
PART V - 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.
12A. SIGNATURE OF APPLICANT (DO NOT PRINT)
12B. DATE SIGNED
VA FORM 22-1990N, JUL 2012

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