Fillable Printable 22 1999C

22 1999C

VA FORM

JUN 2005

22-1999c

VA WILL NOT ACCEPT ANY AFFIRMATION YOU SIGN BEFORE THE 12TH DAY.

EXISTING STOCKS OF VA FORM 22-1999c, APR 2002,

WILL BE USED.

VA WILL NOT PAY FOR LESSONS THAT YOU COMPLETE AND THE SCHOOL SERVICES BEFORE

THE PROPER AFFIRMATION DATE.

VA COPY 1

1. FIRST NAME-MIDDLE INITIAL-LAST NAME OF ELIGIBLE PERSON

3. NAME OF COURSE 4. DATE ENROLLMENT

AGREEMENT SIGNED

2. VA FILE NO.

5. NAME AND ADDRESS OF SCHOOL

6. DATE SIGNED 7. SIGNATURE OF ELIGIBLE PERSON

PURPOSE OF THE AFFIRMATION PROVISION OF LAW

To provide you time (no less than ten full days following your signing of an enrollment agreement) during

which you can reflect on your decision to enroll in a correspondence course and determine if such

correspondence course is suitable to your abilities and interests. The Correspondence School Agreement you

have signed is not effective unless you complete this form and return it to the school.

AFFIRMATION PROCEDURE:

A. Decision not to Affirm - If you decide not to affirm the Correspondence School Agreement you have

signed, do not sign this form. Destroy it. Additionally, you may notify the institution, at any time, of your

decision not to affirm the enrollment agreement. The institution, thereupon, without imposing any penalty or

fee, shall make full refund of all amounts paid.

B. Decision to Affirm - If you decide to affirm the Correspondence School Agreement you have signed, you

may affirm only after the expiration of 10 full days after the day on which the agreement was signed. For

example, if the contract was signed on the 1st day of a month, you must sign and date this affirmation

certification form on or after the 12th day.

TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:

I have read and I understand the enrollment agreement that I entered into with the above named school on the

date indicated in Item 4. By signing this form, I affirm such enrollment agreement and certify, under penalty

of law, that I have not signed this affirmation certificate until after the expiration of 10 full days after the date I

signed the aforesaid enrollment agreement.

(SUBMIT WITH ENROLLMENT CERTIFICATION)

OMB Approved No. 2900-0576

Respondent Burden: 3 Minutes

CERTIFICATE OF AFFIRMATION OF ENROLLMENT AGREEMENT

CORRESPONDENCE COURSE

Under Chapters 30, 32, & 35, Title 38, U.S.C.,

Section 903 of PL 96-342, or Chapter 1606, Title 10, U.S.C.

Respondent Burden: We need this information to determine your eligibility for education benefits based on a

correspondence course and the proper amount payable for that correspondence course. Title 38, United States

Code, allows us to ask for this information. We estimate that you will need an average of 3 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 http;//www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call

1-888-GI-BILL-1 (1-800-442-4551) to get information on where to send comments or suggestions about this

form.

Privacy Act Notice: 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

as identified in the VA system of records, 58VA21/22, Compensation, Pension, Education, and Rehabilitation

Records - VA, published in the Federal Register. An example of a routine use allows VA to send educational

forms or letters with a veteran’s identirying information to the veteran’s school or training establishment to (1)

assist the veteran in the completion of claims forms or (2) for VA to obtain further information as may be

necessary from the school for VA to properly process the veteran’s education claim or to monitor his or her

progress during training. Your obligation to respond is required to obtain or retain benefits. We cannot pay you

any education benefits for taking a correspondence course until we receive this information (38 U.S.C.

3686(b)). Your responses are 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.

VA FORM 22-1999c, JUN 2005