Va Form 22-0839 - Yellow Ribbon Program Agreement Page 4
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5INSTRUCTIONS FOR VA FORM 22-0839
YELLOW RIBBON PROGRAM AGREEMENT
Please read through the instructions before completing the Yellow Ribbon Program Agreement. If you have any
issues completing the form, please send an e-mail to Yellow.Ribbon@va.gov with any inquiries.
General Eligibility
The institution must be an Institution of Higher Learning (IHL) that offers programs of education approved for
VA benefits. In addition, the IHL must be located in the United States or be a branch of such institution located
outside of the United States. Foreign schools are not eligible to participate in the Yellow Ribbon Program.
Name, Address, & Facility Code
Enter the name, mailing address, and facility code, check the type of agreement, and the category of the IHL.
Items 1-5
By signing and submitting this form to VA, the IHL agrees to adhere to the provisions listed in
Items 1-5.
Item 6
Check the appropriate boxes. If other is specified, provide the form of contribution in the space provided. Refer
to Line 4 concerning prohibited sources of funds for institutional contributions.
Item 7
Enter the total number of students for which the IHL will provide Yellow Ribbon Program contributions.
The total number of students entered here should equal the sum of students listed in column A of the table in
Item 8. Enter the dates of the upcoming academic year (e.g., 2013-2014) for which the agreement is being
submitted. (NOTE: An academic year for VA purposes is August 1 to July 31.)
Item 8
A. Maximum Number of Students - Enter the maximum number of students eligible for the specific contribution.
If the IHL wishes to offer Yellow Ribbon Program contributions to an unlimited number of qualifying students,
enter unlimited.
B. Degree Level - Specify the degree level (undergraduate, graduate, doctoral, all) of students for which the
specific contribution will be provided.
C. College or Professional School - This column may be left blank, or specify the appropriate sub-element
(college or professional school) of the institution for which students must be enrolled to receive the specific
contribution. Please be advised that an IHL cannot list a specific degree program (e.g., Masters of
Business Administration, Juris Doctorate, Bachelor of Science in Nursing, etc.)
D. Maximum Contribution Amount - Specify the maximum annual contribution amount to be provided for each
student eligible for the specific contribution. Do not enter the maximum amount payable by term or credit hour. If
the IHL wishes to provide 50% of the unmet established charges for each student eligible for the specific
contribution, please enter unlimited.
NOTE: IHLs must complete columns A and D for each contribution listed. IHLs must also complete column B,
C, or both B and C for each contribution listed.
EXAMPLE:
D. MAXIMUM
B. DEGREE LEVEL
A. MAXIMUM NUMBER
C. COLLEGE OR PROFESSIONAL
CONTRIBUTION
(Undergraduate, Graduate,
OF STUDENTS
SCHOOL
AMOUNT
Doctoral, or All)
10
Undergraduate
2,000
$
15
School of Liberal Arts
1,000
All
$
20
Graduate
School of Business
5,000
$
VA FORM 22-0839, MAY 2012
Page 4
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