Va Form 22-0839 - Yellow Ribbon Program Agreement
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5OMB Control No. 2900-0718
Respondent Burden: 14 hours
YELLOW RIBBON PROGRAM AGREEMENT
(Under Chapter 33 of title 38, United States Code)
IMPORTANT: Please read the instructions for VA Form 22-0839 on pages 4 & 5 before completing the form.
NAME OF INSTITUTION OF HIGHER LEARNING (IHL)
FACILITY CODE
PUBLIC IHL
PRIVATE IHL
(Check one)
MAILING ADDRESS OF INSTITUTION OF HIGHER LEARNING
(Check one)
AGREEMENT TYPE
DATE RECEIVED
(For VA use only)
NEW OPEN-ENDED AGREEMENT
MODIFICATION TO EXISTING AGREEMENT
WITHDRAWAL OF YELLOW RIBBON AGREEMENT
NOTE: If selecting withdrawal of agreement, only the
signature of authorizing official and date are required.
The above named institution of higher learning (IHL) agrees to participate in the Yellow Ribbon Program under the Post-9/11 GI Bill
(authorized under title V of Public Law 110-252) subject to the terms, conditions, and representations provided in this agreement and
applicable VA regulations.
1. Once this agreement is accepted by VA, it will be considered an open-ended agreement that is in effect for the upcoming
academic year and all future academic years unless VA or the Institution notifies the other party that changes are requested.
Withdrawal from the Yellow Ribbon Program or modifications to the terms of the agreement shall only be made during the open
season enrollment period, March 15 - May 15 (or the following Monday if May 15th falls on a Saturday or Sunday). Withdrawal or
modifications to the terms shall be indicated in Agreement Type above. Modifications made during the open enrollment period will
go into effect for the subsequent academic year and will be posted to our website at when the open
enrollment period ends. Please see Page 5 of this form for information about how to submit the completed form.
2. The IHL agrees to provide contributions to eligible individuals who apply for such program at the institution (in a manner
prescribed by the institution) on a first-come-first-served basis.
3. The IHL agrees to provide contributions on behalf of a participating individual during the current academic year and all
subsequent academic years in which the IHL participates in the Yellow Ribbon Program, provided that the individual maintains
satisfactory progress, conduct, and attendance according to the regularly prescribed standards of the institution.
4. The IHL agrees to limit contributions made on behalf of a participant to funds under the unrestricted control of the IHL (e.g., a
scholarship sent directly to an IHL on behalf of an individual or specific group of individuals from a third party may not be
included in Yellow Ribbon Program contributions). Funds received directly or indirectly from Federal sources may not be counted
towards contributions.
5. The IHL agrees to provide the maximum amount of contributions payable toward the net cost for each participating individual
during each term, quarter, or semester the individual is enrolled if the IHL's total contribution toward the individual's net cost for
the term, quarter, or semester does not exceed the maximum dollar amount payable during the academic year as specified in
paragraph 8 of this agreement.
6. The IHL agrees to provide contributions for each Yellow Ribbon Program participant using the following:
Direct Grant
Scholarship
Other
7. The IHL agrees to provide Yellow Ribbon Program contributions for up to _________________ eligible individuals during
the ________________ academic year and all subsequent academic years unless VA is notified of changes during any subsequent
open-enrollment period.
8. The IHL agrees to provide Yellow Ribbon Program contributions for each participant during the academic year up to the
following amounts (fill in all applicable fields):
B. DEGREE LEVEL
D. MAXIMUM
A. MAXIMUM NUMBER
C. COLLEGE OR PROFESSIONAL
(Undergraduate, Graduate,
CONTRIBUTION
OF STUDENTS
SCHOOL
Doctoral, or All)
AMOUNT
$
$
$
$
$
$
$
$
$
$
$
$
(Attach additional listings if necessary)
VA FORM
SUPERSEDES VA FORM 22-0839, JAN 2012,
22-0839
Page 1
MAY 2012
WHICH WILL NOT BE USED.
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