Va Form 22-5495 - Dependents' Request For Change Of Program Or Place Of Training Page 2

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PART IV - BENEFIT AND TYPE OF EDUCATION OR TRAINING

21A. TYPE OF BENEFIT

CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT JOHN DAVID FRY SCHOLARSHIP (FRY SCHOLARSHIP)

CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE PROGRAM (DEA)

21B. TYPE OF TRAINING

NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT

COLLEGE OR OTHER SCHOOL

(DEA Children not eligible)

FARM COOPERATIVE

CORRESPONDENCE COURSE

LICENSING OR CERTIFICATION TEST

(Fry Scholarship only)

FLIGHT TRAINING

APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING

(e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)

22. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE

23. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING TO PURSUE?

24. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS OF NEW

25. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS

SCHOOL OR TRAINING ESTABLISHMENT YOU PLAN TO ATTEND

OF CURRENT OR OLD SCHOOL OR TRAINING ESTABLISHMENT

(if applicable)

26. TELL US WHEN AND WHY YOU STOPPED (or will stop) TRAINING AT YOUR OLD (or current) SCHOOL OR TRAINING ESTABLISHMENT

PART V - REMARKS AND CERTIFICATION

(If more space is needed, please attach a separate sheet of paper. Be sure to include name and social security number on each sheet of paper)

27. REMARKS

I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.

PENALTY - Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of

these or other benefits and in criminal penalties.

28A. SIGNATURE OF APPLICANT (DO NOT PRINT)

28B. DATE SIGNED

Sign Here

In INK

VA FORM 22-5495, DEC 2016

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