enfermeria

OMB Approved No. 2900-0099
Respondent Burden: 15 Minutes

REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
SURVIVORS’ AND DEPENDENTS’ EDUCATION ASSISTANCE
(Under Provisions of Chapter 35, Title 38, U.S.C.)
INTERNET VERSION AVAILABLE
You can submit this application over the Internet at the following site: www.gibill.va.gov
PART I - ALL APPLICANTS
1. NAME OF APPLICANT (First, Middleinitial, Last)

2A. VA FILE NUMBER

2B. SUFFIX LETTER

3. NAME OF VETERAN (First, Middle initial, Last)

4A. VETERAN’S SOCIAL SECURITY NO.

4B. APPLICANT’S SOCIAL SECURITY NUMBER

5. MAILING ADDRESS (Number and street or rural route, city or P.O., State and 9 DIGIT ZIP Code)

6. IF YOU ARE OR HAVE EVER BEEN ON ACTIVE MILITARY DUTY, GIVE THE DATE (MONTH,DAY, YEAR) YOU BEGAN THIS ACTIVEDUTY

7A. THIS QUESTION IS FOR FEDERAL CIVILIAN EMPLOYEES OF THE UNITED STATES GOVERNMENT. IT IS NOT FOR ACTIVE DUTY PERSONS OR WORK-STUDY
RECIPIENTS. IF YOU ARE A CIVILIAN EMPLOYEE OF THE FEDERAL GOVERNMENT, CHECK "YES" IN THIS ITEM. THEN COMPLETE ITEM 7B.
NO
YES
7B. (ONLY COMPLETE THIS BLOCK IF YOU CHECKED "YES" IN ITEM 7A). IF YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR DEPARTMENT FORTHE SAME COURSE FOR WHICH YOU EXPECT TO RECEIVE VA EDUCATIONAL ASSISTANCE, YOU MUST CHECK "YES." THEN DESCRIBE IN DETAIL THE
SOURCE OF THESE FUNDS. PLACE THIS INFORMATION IN ITEM 15, REMARKS.
YES

NO

PART II - SPOUSES AND SURVIVING SPOUSE ONLY
8. IF YOU ARE THE SPOUSE OF A DISABLED VETERAN, IS A DIVORCE OR AN ANNULMENT PENDING?
YES

NO

9A. IF YOU ARE THE SURVIVING SPOUSE, HAVE YOUREMARRIED SINCE THE DEATH OF THE VETERAN? 9B. DATE THAT YOU REMARRIED (Month, Year)
YES

NO

(If "Yes," complete 9B)
PART III - YOUR PROGRAM

10. WHAT IS YOUR SPECIFIC EDUCATIONAL OR CAREER GOAL?

11. HAVE YOU SELECTED THE SPECIFIC PROGRAM OF EDUCATION YOU PLAN TO TAKE? (If "Yes", list each diploma and specific degree or vocational course
you need to reach the final degree or occupationshown in Item 10. If "No", leave this Item blank.)
NO
YES
12. EDUCATION OR TRAINING WILL BE BY (Check more than one if necessary)
COLLEGE OR OTHER SCHOOL

CORRESPONDENCE (Spouses and Surviving Spouses Only)

COOPERATIVE TRAINING

I SEEK REIMBURSEMENT FOR A LICENSING OR CERTIFICATION TEST
APPRENTICESHIP OR ON-THE-JOB TRAINING
13A. NAME AND ADDRESS (City, State and ZIP Code) OF YOUR NEWSCHOOL OR TRAINING ESTABLISHMENT

13B. NAME AND ADDRESS (City, State and ZIP Code) OF YOUR OLD SCHOOL OR TRAINING ESTABLISHMENT

14. TELL US WHEN AND WHY YOU STOPPED TRAINING AT YOUR OLD SCHOOL OR ESTABLISHMENT

15. REMARKS (If more space is needed, use the reverse or attach a separate sheet of paper)

CERTIFICATION AND SIGNATURE OF APPLICANT

I CERTIFY THAT all statements in myapplication are true and correct to the best of my knowledge and belief.
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.
16A. SIGNATURE OF APPLICANT (DO NOT PRINT)

VA FORM
JAN 2004

22-5495

16B. DATE SIGNED

EXISTING STOCKS OF VA FORM22-5495, AUG 2002,
WILL BE USED.

INFORMATION AND INSTRUCTIONS
FOR COMPLETING THE REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
SURVIVORS’ AND DEPENDENTS’ EDUCATION ASSISTANCE
HOW TO USE THESE INSTRUCTIONS AND APPLY FOR BENEFITS
This form is available on the Internet. You may file your application electronically by going to" www.gibill.va.gov".
To submit your application electronically,click on the "electronic application form" and follow the instructions for
VA Form 22-5495.
To complete a "PDF" version of this form, click on the "education forms", and scroll down to VA Form 22-5495.
(You must then print the completed PDF form. After completing and printing, see HOW TO FILE YOUR CLAIM on the reverse.)
Tear off these instructions from the remainder of the form. Placing these...