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tÉlÉcharger va form 21-674 pdf

OMB Approved No. 2900-0049
Respondent Burden: 15 minutes
Expiration Date: 06/30/2021
1. ADDRESS OF VA OFFICE
REQUEST FOR APPROVAL OF SCHOOL ATTENDANCE
IMPORTANT - Be sure to read the Instructions on the reverse of Copy 1 before completing this form. The form should be completed in duplicate and signed in Part III.
PART I - TO BE COMPLETED BY CLAIMANT (Also sign certification in Part III)
2A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF VETERAN (Type or Print) 2B. E-Mail ADDRESS OF VETERAN (If
applicable)
3. VA FILE NUMBER
C/CSS
4A. FIRST NAME-MIDDLE INITIAL-LAST NAME OF STUDENT (Veteran's child attending school) (Type or print)
4B. STUDENT'S SOCIAL SECURITY NUMBER
5B. HAS STUDENT EVER MARRIED?
5A. DATE OF BIRTH
YES
NO
6. ADDRESS OF STUDENT (Number and street or rural route, city
or P.O., State and Zip Code)
5C. DATE OF MARRIAGE
(If "Yes," complete Item 5C)
7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID BY
VA DEPENDENTS EDUCATIONAL ASSISTANCE (DEA), THE FEDERAL EMPLOYEE'S
COMPENSATION ACT OR ANY OTHER AGENCY OR PROGRAM OF THE UNITED STATES
GOVERNMENT?
YES
NO
(If "Yes," complete Items 7B and 7C. If "No," skip to Item 8A)
7B. AGENCY NAME
7C. DATE PAYMENTS BEGAN (Month, day, year)
8A. NAME AND ADDRESS OF SCHOOL FOR WHICH APPROVAL IS REQUESTED
8B. NAME OR TYPE OF COURSE OF EDUCATION OR TRAINING
9A. OFFICIAL BEGINNING DATE OF REGULAR TERM OR
COURSE (Month, day, year)
10A. IS STUDENT ENROLLED IN A FULLTIME HIGH SCHOOL
OR COLLEGE COURSE?
YES
NO
9B. DATE STUDENT STARTED OR EXPECTS TO START
COURSE (Month, day, year)
10B. SUBJECT FOR WHICH STUDENT IS ENROLLED
(If other than full-time high school or college course)
9C. EXPECTED DATE OF GRADUATION
(Month, day, year)
10D. HOURS
PER WEEK
10C. NUMBER OF
SESSIONS PER WEEK
(If "No," complete Items
10B, 10C and 10D)
11A. WAS STUDENT ATTENDING ANY SCHOOL AT END OF
LAST SCHOOL TERM?
11B. NAME AND ADDRESS OF SCHOOL ATTENDED LAST TERM
NO (If "Yes," complete Items 11B thru 11F)
YES
11D. HOURS PER WEEK
11C. NO. OF SESSIONS
PER WEEK
11E. BEGINNING DATE OF LAST TERM
11F. ENDING DATE OF LAST TERM
PART II - STUDENT'S INCOME AND NET WORTH (See instructions on reverse for when required)
12. REPORT OF INCOME BY CALENDAR YEAR (IMPORTANT - Do NOT report VA benefits)
A. SOURCE
B. RECEIVED
(REPORT FOR YEAR IN WHICH SCHOOL
TERM BEGINS-SEE ITEM 9 ABOVE)
EARNINGS FROM
ALL EMPLOYMENT
C. EXPECTED
(Report for year following
that shown in Column B)
13. VALUE OF ESTATE
A. SAVINGS
$
(Including cash)
B. SECURITIES, BONDS,
ETC.
ANNUAL SOCIAL
SECURITY
C. REAL ESTATE
OTHER
ANNUITIES
D. ALL OTHER ASSETS
ALL OTHER INCOME
(Interest, dividends, etc.)
(Not your home)
E. TOTAL OF ABOVE
$
14. REMARKS
PART III - CERTIFICATION AND AGREEMENT TO BE SIGNED BY CLAIMANT
NOTE: This part will be completed by the student only if he or she has attained majority and is claiming benefits in his or her own right. Otherwise, the veteran, surviving
spouse, guardian or custodian will sign and also enter his or her relationship to the student.
Receipt by the student of VA Dependents Educational Assistance (DEA), the Federal Employee's Compensation Act, or benefit from another Federal Agency (U.S. Service
Academy, U.S. Merchant Marine Academy, Bureau of Indian Affairs, etc.) with additional compensation payments based on the student's school attendance is considered a
duplication of benefits and is prohibited.
I CERTIFY THAT the information given above is true and correct to the best of my knowledge and belief and request approval of the course of education or training shown above.
I AGREE to notify the Department of Veterans Affairs immediately of any changes in this course of education, transfer to another school, discontinuance of school
attendance, receipt of Dependents Educational Assistance, or marriage prior to completion of the course. I understand that continued entitlement to school attendance may be
based on information I have furnished on this form. Any benefits allowed due to this certification will be discontinued if the student marries, receives VA Dependents
Education Assistance (DEA) benefits, leaves school, or passes away.