Self Certification Of Full Time School Attendance Page 2
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1
2Instructions for Completing the Enclosed Form
It Is Important That You Follow All Of The Instructions Below.
1.
The enclosed form has been designed to allow your answers to be read using optical scanning equipment. Therefore,
please use a pencil to blacken the ovals. If you make a mistake, erase it completely and blacken the correct oval. (Do not
use a correction fluid on the enclosed form.)
2.
Complete the form as illustrated in the example below:
EXAMPLE
Item 10 of the form is reproduced here to illustrate how you should make your entries on this form. The example below
illustrates how this question would be completed for a student whose school year ends or will end on June 7, 2011.
10. Enter the date this school attendance will end
or ended. If the student plans to attend for
the full school year, you should show the
Write the month, day, and year in the boxes.
ending date of the full school year (NOT the
If the month is June, enter JUN.
semester). This date must be later than the
date shown in block 9.
Month
Day
Year
U N
J
0
1
1
7
0
0
0
JAN
FEB
1
1
1
1
Blacken the corresponding oval below each
box. For example, if the number is "0,"
MAR
2
2
2
2
blacken the oval with a "0" in it.
APR
3
3
3
3
MAY
4
4
4
JUN
5
5
5
JUL
6
6
6
AUG
7
7
SEP
8
8
8
9
9
9
OCT
NOV
DEC
3.
Please review your entries to avoid delays in your payments due to errors or incomplete data.
4.
DO NOT copy or duplicate the self-certification form. If you need another form, write to the address shown in item 5, call us
on (202) 606-0249, or go to our website at
DO NOT staple, damage, or mutilate the form.
5.
The person who is the payee must be sure to sign the form and submit it within 30 days. To reply by mail, use the enclosed
envelope addressed to:
U.S. Office of Personnel Management
Surveys and Students Branch - Attn: Room 2309
1900 E Street, NW
Washington, D.C. 20415-3563
Or, you may fax your completed form to (202) 606-0022.
If you need assistance:
If, after carefully reading the instructions, you need assistance to complete the form on regular work days, you may contact
us from 7:30 a.m. to 5:00 p.m. (Eastern Time) on (202) 606-0249. If you have any other questions regarding student
benefits, please call us at 1-888-767-6738.
Reverse of RI 25-14A
Revised June 2011
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