Va Form 28-8832 - 2008 Educational/vocational Counseling Application printable pdf download

OMB Approved No. 2900-0265

Respondent Burden: 30 minutes

EDUCATIONAL/VOCATIONAL COUNSELING APPLICATION

PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been authorized under the

Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records, 58VA21/22/28, Compensation,

Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to

obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1).

The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect

prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The

responses you submit are considered confidential (38 U.S.C. 5701). Any information provided by applicants, recipients, and others may be subject to verification

through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine if the veteran and other beneficiaries are eligible for counseling services that VR&E services

proivde. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions,

find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are

not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at

If desired, you can call 1-800-827-1000 to get information on where to send comments or

suggestions about this form.

INTERNET VERSION AVAILABLE -You may download this application form at

PART I - APPLICANT INFORMATION

(FIRST-MIDDLE-LAST)

(If known)

1B. SOCIAL SECURITY NUMBER OF APPLICANT

1A. NAME OF APPLICANT

1C. VA FILE NUMBER

2A. SEX OF APPLICANT

2B. APPLICANT'S E-MAIL ADDRESS

2C. DATE OF BIRTH

MALE

FEMALE

(Including Area Code)

3A. RELATIONSHIP OF APPLICANT TO VETERAN

3B. APPLICANT'S TELEPHONE NUMBER

(Where a message

OTHER PHONE NUMBER

PRIMARY PHONE NUMBER

SELF

SURVIVING SPOUSE

CHILD

can be left)

SPOUSE

STEPCHILD

ADOPTED CHILD

(Number and street or rural route, city or P.O., State and ZIP Code)

VA DATE STAMP

3C. MAILING ADDRESS OF APPLICANT

(For VA Use Only)

4A. ARE YOU A CHILD, 14 YEARS OR OLDER,

4B. ARE YOU A CHILD, SPOUSE, OR

5. HAVE YOU RECEIVED AN INFORMATION PAMPHLET

SPOUSE, OR SURVIVING SPOUSE WITH A

SURVIVING SPOUSE WITH A DISABILITY

EXPLAINING SURVIVORS' AND DEPENDENTS'

EDUCATIONAL ASSISTANCE BENEFITS?

DISABILITY SEEKING SPECIAL RESTORATIVE

SEEKING SPECIAL VOCATIONAL TRAINING?

TRAINING?

YES

PART II - INFORMATION CONCERNING DISABLED OR DECEASED VETERAN OR INDIVIDUAL ON ACTIVE DUTY

(FIRST- MIDDLE -LAST)

6A. NAME OF VETERAN OR INDIVIDUAL ON ACTIVE DUTY ON WHOSE ACCOUNT BENEFITS ARE CLAIMED

(If known)

6C. VA FILE NUMBER

6B. SOCIAL SECURITY NUMBER

7. DATE OF BIRTH

8. BRANCH OF SERVICE

9. SERVICE NUMBER

10. DATE OF DEATH OR DATE LISTED

AS MISSING IN ACTION OR P.O.W.

PART III - SPECIAL INFORMATION CONCERNING APPLICANT

11. IF YOU ARE THE SPOUSE OF A DISABLED VETERAN, IS A DIVORCE OR ANNULMENT PENDING?

YES

12B. SURVIVING SPOUSE'S AGE AT TIME OF REMARRIAGE

12A. IF YOU ARE THE SURVIVING SPOUSE OF A DECEASED VETERAN, HAVE YOU

REMARRIED SINCE HIS OR HER DEATH ?

YES

(Check applicable box(es))

13. HAVE YOU EVER APPLIED FOR ANY OF THE FOLLOWING VA BENEFITS?

(Chapter 31)

VOCATIONAL REHABILITATION BENEFITS

(Specify benefit)

VETERANS' EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE

(Chapter 35)

DEPENDENTS' EDUCATIONAL ASSISTANCE

(Complete Items 14A and 14B) on reverse)

SURVIVORS' AND DEPENDENTS EDUCATIONAL ASSISTANCE

(Specify)

OTHER

NONE

VA FORM

SUPERSEDES VA FORM 28-8832, JAN 2007,

28-8832

Testing POC

DEC 2008

WHICH WILL NOT BE USED.

Dr. George Davis

WK: 757-826-5584

Fax 757-826-5691

Va Form 28-8832 - 2008 Educational/vocational Counseling Application

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