VA Form 22-1995 Fillable Template

STOP EFT A. TYPE OF ACCOUNT CHECKING SAVINGS B. NAME OF FINANCIAL INSTITUTION VA FORM DEC 2016 22-1995 C. 9 DIGIT ROUTING OR TRANSIT NUMBER SUPERSEDES VA FORM 22-1995 OCT 2015 WHICH WILL NOT BE USED. D. ACCOUNT NUMBER Page 1 PART IV - MISCELLANEOUS INFORMATION 6. 11A. SIGNATURE OF APPLICANT DO NOT PRINT 11B. DATE SIGNED SIGN HERE IN INK VA FORM 22-1995 DEC 2016 Page 2 INSTRUCTIONS INFORMATION When Should You Use This Form Use this form when you re changing schools you left your program due to unsatisfactory attendance progress or conduct and you re now reentering the same program or you were receiving VA education benefits as a veteran and now wish to receive benefits while on active military duty. OMB Control No* 2900-0074 Respondent Burden 20 Minutes Expiration Date 05-31-2018 REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING PART I - IDENTIFICATION AND PERSONAL INFORMATION 1A. NAME OF APPLICANT Last First Middle VA DATE STAMP DO NOT WRITE IN THIS SPACE 1B. MAILING ADDRESS Complete street address City State and 9-digit ZIP Code 1C. APPLICANT S TELEPHONE NUMBER Including Area Code 1D. VA FILE NUMBER EVENING DAY 1F* SOCIAL SECURITY OF APPLICANT For transferability cases enter the veteran s social security number 1E* APPLICANT S E-MAIL ADDRESS PART II - YOUR PROGRAM INFORMATION 2. EDUCATION BENEFIT YOU WANT TO RECEIVE Only Select One A. B. CHAPTER 33 Post-9/11 GI BILL C. CHAPTER 30 Montgomery GI Bill - D. Active Duty CHAPTER 32 Veterans Educational Assistance Program including section 903 CHAPTER 1606 Montgomery GI BillSelected Reserve E* CHAPTER 1607 Reserve Educational Assistance Program F* TRANSFER OF ENTITLEMENT PROGRAM COOPERATIVE TRAINING G* LICENSING CERTIFICATION TEST TUITION ASSISTANCE TOP-UP H. NATIONAL ADMISSIONS EXAMS OR NATIONAL EXAMS FOR CREDIT 3. HOW WILL YOU TAKE TRAINING SCHOOL ATTENDANCE CORRESPONDENCE APPRENTICESHIP OR ON-THE-JOB TRAINING FLIGHT TRAINING 4A. WHAT EDUCATIONAL PROFESSIONAL OR VOCATIONAL GOAL ARE YOU WORKING TOWARD 4B. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING 4C. IF CHANGING SCHOOLS PROVIDE NAME AND COMPLETE ADDRESS OF NEW SCHOOL OR TRAINING ESTABLISHMENT YOU ARE PLANNING TO ATTEND If applicable 4D. PROVIDE NAME AND COMPLETE ADDRESS OF PREVIOUS SCHOOL OR TRAINING ESTABLISHMENT If only changing schools list current school* 4E* TELL US WHEN AND WHY YOU STOPPED TRAINING AT YOUR PRIOR SCHOOL OR ESTABLISHMENT. CONTINUE IN REMARKS ITEM 10 OR ON A SEPARATE SHEET IF NECESSARY. PART III - DIRECT DEPOSIT INFORMATION 5. DIRECT DEPOSIT Complete this item only if you wish to start change or stop direct deposit. NOTE To prevent possible delays in payment claimants are highly encouraged to use Direct Deposit and set up an Electronic Fund Transfer EFT. Direct Deposit is not available for the Post-Vietnam Era Educational Assistance Program VEAP - Chapter 32 nor for Section 903. START OR CHANGE EFT Please attach a voided personal check or provide the information in items A through D below. INFORMATION ON DEPENDENTS COMPLETE THIS ITEM ONLY IF YOU SERVED BEFORE JANUARY 1 1977 or had a delayed entry before January 2 1978 AND YOU CURRENTLY HAVE DEPENDENTS* QUESTIONS YES NO A.