Dd Form 2941 - Statement Of Irrevocable Election Of Educational Assistance Benefits
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1STATEMENT OF IRREVOCABLE ELECTION OF EDUCATIONAL ASSISTANCE BENEFITS
BASED ON QUALIFYING FOR EDUCATIONAL ASSISTANCE
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 1607; 38 U.S.C. Chapter 30; and EO 9397 (SSN).
PRINCIPAL PURPOSE(S): To record a member's selection of educational assistance program.
ROUTINE USE(S): To the Department of Veterans Affairs to report payment information for members who participated in making
contributions to the Reserve Educational Assistance Program (REAP).
DISCLOSURE: Voluntary. However, failure to provide the requested information may preclude processing of the Reserve
Educational Assistance Program eligibility documentation and could prevent participation in the selected program.
1. MEMBER'S INFORMATION
a. NAME (Last, First, Middle Initial)
b. RANK
c. SSN
d. SERVICE
e. COMPONENT (National Guard or Reserve)
f. CATEGORY (Reserve Affiliation) (X one)
SELECTED
INDIVIDUAL READY
RESERVE
RESERVE (IRR)
2. STATEMENT OF ELECTION
Based upon my continuous performance of active service from
to
,
(YYYYMMDD)
(YYYYMMDD)
I am entitled to educational assistance under both Chapter 30 of Title 38, United States Code (U.S.C.), pertaining to the
Montgomery G.I. Bill, and Chapter 1607 of Title 10, U.S.C., pertaining to Reserve Component members called or ordered to
active service in support of contingency operations and for members of the Army or Air National Guard, certain national
emergency response operations.
Fully understanding that I may not receive credit under both programs based on the same period of active service, and that I
must make an IRREVOCABLE ELECTION as to which program of educational assistance such service is to be credited, I make
the following election.
I want my qualifying active service indicated above to be credited toward the program of educational
(Initial)
assistance established by Chapter 30 of Title 38, U.S.C., (Montgomery G.I. Bill - Active Duty) and understand that I MUST
CONTRIBUTE $1200.00 AND PROVIDE PROOF OF SUCH PAYMENT prior to this election being validated by my Service and
before I can submit a claim to the Department of Veterans Affairs.
I want my active service indicated above to be credited toward the program of educational assistance
(Initial)
established by Chapter 1607 of Title 10, U.S.C. I understand that there is no monetary contribution required on my part.
3. MEMBER
a. SIGNATURE
b. DATE (YYYYMMDD)
4. AUTHORIZED SERVICE POINT OF CONTACT
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE (YYYYMMDD)
DD FORM 2941, JAN 2009
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