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Fillable Printable 22 1999C

Fillable Printable 22 1999C

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 COURSE4. DATE ENROLLMENT
AGREEMENT SIGNED
2. VA FILE NO.
5. NAME AND ADDRESS OF SCHOOL
6. DATE SIGNED7. SIGNATURE OF ELIGIBLE PERSON
PURPOSE OF THE AFFIRMATION PROVISION OF LAW
Toprovideyoutime(nolessthantenfulldaysfollowingyoursigningofanenrollmentagreement)during
whichyoucanreflectonyourdecisiontoenrollinacorrespondencecourseanddetermineifsuch
correspondencecourseissuitabletoyourabilitiesandinterests.TheCorrespondenceSchoolAgreementyou
have signed is not effective unless you complete this form and return it to the school.
AFFIRMATION PROCEDURE:
A.DecisionnottoAffirm-IfyoudecidenottoaffirmtheCorrespondenceSchoolAgreementyouhave
signed,donotsignthisform.Destroyit.Additionally,youmaynotifytheinstitution,atanytime,ofyour
decisionnottoaffirmtheenrollmentagreement.Theinstitution,thereupon,withoutimposinganypenaltyor
fee, shall make full refund of all amounts paid.
B.DecisiontoAffirm-IfyoudecidetoaffirmtheCorrespondenceSchoolAgreementyouhavesigned,you
mayaffirmonlyaftertheexpirationof10fulldaysafterthedayonwhichtheagreementwassigned.For
example,ifthecontractwassignedonthe1stdayofamonth,youmustsignanddatethisaffirmation
certificationformonorafterthe12thday.
TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:
IhavereadandIunderstandtheenrollmentagreementthatIenteredintowiththeabovenamedschoolonthe
dateindicatedinItem4.Bysigningthisform,Iaffirmsuchenrollmentagreementandcertify,underpenalty
oflaw,thatIhavenotsignedthisaffirmationcertificateuntilaftertheexpirationof10fulldaysafterthedateI
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.
RespondentBurden:Weneedthisinformationtodetermineyoureligibilityforeducationbenefitsbasedona
correspondencecourseandtheproperamountpayableforthatcorrespondencecourse.Title38,UnitedStates
Code,allowsustoaskforthisinformation.Weestimatethatyouwillneedanaverageof3minutestoreview
theinstructions,findtheinformation,andcompletethisform.VAcannotconductorsponsoracollectionof
informationunlessavalidOMBcontrolnumberisdisplayed.Youarenotrequiredtorespondtoacollectionof
informationifthisnumberisnotdisplayed.ValidOMBcontrolnumberscanbelocatedontheOMBInternet
Pageathttp;//www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA.Ifdesired,youcancall
1-888-GI-BILL-1(1-800-442-4551)togetinformationonwheretosendcommentsorsuggestionsaboutthis
form.
PrivacyActNotice:VAwillnotdiscloseinformationcollectedonthisformtoanysourceotherthanwhathas
beenauthorizedunderthePrivacyActof1974orTitle38,CodeofFederalRegulations1.576forroutineuses
asidentifiedintheVAsystemofrecords,58VA21/22,Compensation,Pension,Education,andRehabilitation
Records-VA,publishedintheFederalRegister.AnexampleofaroutineuseallowsVAtosendeducational
formsorletterswithaveteran’sidentiryinginformationtotheveteran’sschoolortrainingestablishmentto(1)
assisttheveteraninthecompletionofclaimsformsor(2)forVAtoobtainfurtherinformationasmaybe
necessaryfromtheschoolforVAtoproperlyprocesstheveteran’seducationclaimortomonitorhisorher
progressduringtraining.Yourobligationtorespondisrequiredtoobtainorretainbenefits.Wecannotpayyou
anyeducationbenefitsfortakingacorrespondencecourseuntilwereceivethisinformation(38U.S.C.
3686(b)).Yourresponsesareconfidential(38U.S.C.5701).Anyinformationprovidedbyapplicants,
recipients, and others may be subject to verification through computer matching programs with other agencies.
VA FORM 22-1999c, JUN 2005
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.
SCHOOL COPY 2
1. FIRST NAME-MIDDLE INITIAL-LAST NAME OF ELIGIBLE PERSON
3. NAME OF COURSE4. DATE ENROLLMENT
AGREEMENT SIGNED
2. VA FILE NO.
5. NAME AND ADDRESS OF SCHOOL
6. DATE SIGNED7. SIGNATURE OF ELIGIBLE PERSON
PURPOSE OF THE AFFIRMATION PROVISION OF LAW
Toprovideyoutime(nolessthantenfulldaysfollowingyoursigningofanenrollmentagreement)during
whichyoucanreflectonyourdecisiontoenrollinacorrespondencecourseanddetermineifsuch
correspondencecourseissuitabletoyourabilitiesandinterests.TheCorrespondenceSchoolAgreementyou
have signed is not effective unless you complete this form and return it to the school.
AFFIRMATION PROCEDURE:
A.DecisionnottoAffirm-IfyoudecidenottoaffirmtheCorrespondenceSchoolAgreementyouhave
signed,donotsignthisform.Destroyit.Additionally,youmaynotifytheinstitution,atanytime,ofyour
decisionnottoaffirmtheenrollmentagreement.Theinstitution,thereupon,withoutimposinganypenaltyor
fee, shall make full refund of all amounts paid.
B.DecisiontoAffirm-IfyoudecidetoaffirmtheCorrespondenceSchoolAgreementyouhavesigned,you
mayaffirmonlyaftertheexpirationof10fulldaysafterthedayonwhichtheagreementwassigned.For
example,ifthecontractwassignedonthe1stdayofamonth,youmustsignanddatethisaffirmation
certificationformonorafterthe12thday.
TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:
IhavereadandIunderstandtheenrollmentagreementthatIenteredintowiththeabovenamedschoolonthe
dateindicatedinItem4.Bysigningthisform,Iaffirmsuchenrollmentagreementandcertify,underpenalty
oflaw,thatIhavenotsignedthisaffirmationcertificateuntilaftertheexpirationof10fulldaysafterthedateI
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.
RespondentBurden:Weneedthisinformationtodetermineyoureligibilityforeducationbenefitsbasedona
correspondencecourseandtheproperamountpayableforthatcorrespondencecourse.Title38,UnitedStates
Code,allowsustoaskforthisinformation.Weestimatethatyouwillneedanaverageof3minutestoreview
theinstructions,findtheinformation,andcompletethisform.VAcannotconductorsponsoracollectionof
informationunlessavalidOMBcontrolnumberisdisplayed.Youarenotrequiredtorespondtoacollectionof
informationifthisnumberisnotdisplayed.ValidOMBcontrolnumberscanbelocatedontheOMBInternet
Pageathttp;//www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA.Ifdesired,youcancall
1-888-GI-BILL-1(1-800-442-4551)togetinformationonwheretosendcommentsorsuggestionsaboutthis
form.
PrivacyActNotice:VAwillnotdiscloseinformationcollectedonthisformtoanysourceotherthanwhathas
beenauthorizedunderthePrivacyActof1974orTitle38,CodeofFederalRegulations1.576forroutineuses
asidentifiedintheVAsystemofrecords,58VA21/22,Compensation,Pension,Education,andRehabilitation
Records-VA,publishedintheFederalRegister.AnexampleofaroutineuseallowsVAtosendeducational
formsorletterswithaveteran’sidentiryinginformationtotheveteran’sschoolortrainingestablishmentto(1)
assisttheveteraninthecompletionofclaimsformsor(2)forVAtoobtainfurtherinformationasmaybe
necessaryfromtheschoolforVAtoproperlyprocesstheveteran’seducationclaimortomonitorhisorher
progressduringtraining.Yourobligationtorespondisrequiredtoobtainorretainbenefits.Wecannotpayyou
anyeducationbenefitsfortakingacorrespondencecourseuntilwereceivethisinformation(38U.S.C.
3686(b)).Yourresponsesareconfidential(38U.S.C.5701).Anyinformationprovidedbyapplicants,
recipients, and others may be subject to verification through computer matching programs with other agencies.
VA FORM 22-1999c, JUN 2005
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.
STUDENT COPY 3
1. FIRST NAME-MIDDLE INITIAL-LAST NAME OF ELIGIBLE PERSON
3. NAME OF COURSE4. DATE ENROLLMENT
AGREEMENT SIGNED
2. VA FILE NO.
5. NAME AND ADDRESS OF SCHOOL
6. DATE SIGNED7. SIGNATURE OF ELIGIBLE PERSON
PURPOSE OF THE AFFIRMATION PROVISION OF LAW
Toprovideyoutime(nolessthantenfulldaysfollowingyoursigningofanenrollmentagreement)during
whichyoucanreflectonyourdecisiontoenrollinacorrespondencecourseanddetermineifsuch
correspondencecourseissuitabletoyourabilitiesandinterests.TheCorrespondenceSchoolAgreementyou
have signed is not effective unless you complete this form and return it to the school.
AFFIRMATION PROCEDURE:
A.DecisionnottoAffirm-IfyoudecidenottoaffirmtheCorrespondenceSchoolAgreementyouhave
signed,donotsignthisform.Destroyit.Additionally,youmaynotifytheinstitution,atanytime,ofyour
decisionnottoaffirmtheenrollmentagreement.Theinstitution,thereupon,withoutimposinganypenaltyor
fee, shall make full refund of all amounts paid.
B.DecisiontoAffirm-IfyoudecidetoaffirmtheCorrespondenceSchoolAgreementyouhavesigned,you
mayaffirmonlyaftertheexpirationof10fulldaysafterthedayonwhichtheagreementwassigned.For
example,ifthecontractwassignedonthe1stdayofamonth,youmustsignanddatethisaffirmation
certificationformonorafterthe12thday.
TO AFFIRM, READ THE FOLLOWING PARAGRAPH AND COMPLETE ITEMS 6 AND 7 BELOW:
IhavereadandIunderstandtheenrollmentagreementthatIenteredintowiththeabovenamedschoolonthe
dateindicatedinItem4.Bysigningthisform,Iaffirmsuchenrollmentagreementandcertify,underpenalty
oflaw,thatIhavenotsignedthisaffirmationcertificateuntilaftertheexpirationof10fulldaysafterthedateI
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.
RespondentBurden:Weneedthisinformationtodetermineyoureligibilityforeducationbenefitsbasedona
correspondencecourseandtheproperamountpayableforthatcorrespondencecourse.Title38,UnitedStates
Code,allowsustoaskforthisinformation.Weestimatethatyouwillneedanaverageof3minutestoreview
theinstructions,findtheinformation,andcompletethisform.VAcannotconductorsponsoracollectionof
informationunlessavalidOMBcontrolnumberisdisplayed.Youarenotrequiredtorespondtoacollectionof
informationifthisnumberisnotdisplayed.ValidOMBcontrolnumberscanbelocatedontheOMBInternet
Pageathttp;//www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA.Ifdesired,youcancall
1-888-GI-BILL-1(1-800-442-4551)togetinformationonwheretosendcommentsorsuggestionsaboutthis
form.
PrivacyActNotice:VAwillnotdiscloseinformationcollectedonthisformtoanysourceotherthanwhathas
beenauthorizedunderthePrivacyActof1974orTitle38,CodeofFederalRegulations1.576forroutineuses
asidentifiedintheVAsystemofrecords,58VA21/22,Compensation,Pension,Education,andRehabilitation
Records-VA,publishedintheFederalRegister.AnexampleofaroutineuseallowsVAtosendeducational
formsorletterswithaveteran’sidentiryinginformationtotheveteran’sschoolortrainingestablishmentto(1)
assisttheveteraninthecompletionofclaimsformsor(2)forVAtoobtainfurtherinformationasmaybe
necessaryfromtheschoolforVAtoproperlyprocesstheveteran’seducationclaimortomonitorhisorher
progressduringtraining.Yourobligationtorespondisrequiredtoobtainorretainbenefits.Wecannotpayyou
anyeducationbenefitsfortakingacorrespondencecourseuntilwereceivethisinformation(38U.S.C.
3686(b)).Yourresponsesareconfidential(38U.S.C.5701).Anyinformationprovidedbyapplicants,
recipients, and others may be subject to verification through computer matching programs with other agencies.
VA FORM 22-1999c, JUN 2005
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