VA Form 21-8938-1 Student Beneficiary Report - REPS (Restored Entitlement

OMB Control No. 2900-0399
Respondent Burden: 20 Minutes

STUDENT BENEFICIARY REPORT - REPS
(RESTORED ENTITLEMENT PROGRAM FOR SURVIVORS)
PRIVACY ACT NOTICE: The 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 5, Code of
Federal Regulations 1.526 for routine uses (i.e., (Routine Uses 1 through 63) as identified in the VA system of records, 58VA21/22, Compensation, Pension, Education and Rehabilitation
Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. No benefits may
be granted unless this form is completed fully as required by law (38 U.S.C. 5101). Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an
individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
RESPONDENT BURDEN: We need this information in order to determine your continued eligibility for REPS payments as a student beneficiary. Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 20 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 www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to
send comments or suggestions about this form.

SECTION I - STUDENT IDENTIFICATION
1A. NAME AND ADDRESS OF STUDENT (First, middle, last name)

1B. VETERAN/WAGE EARNER’S SOCIAL SECURITY NO.

1C. STUDENT’S SOCIAL SECURITY NO.

2. PERIOD OF ATTENDANCE
A. BEGINNING DATE
(Month, day, year)

B. ENDING DATE
(Month, day, year)

(If different from above, furnish current address)
INSTRUCTIONS: STUDENTS - You must complete Section II, Student Certification, and have a school official verify your attendance. SCHOOL
OFFICIALS - Please complete Section III, School Official Certification, and return it promptly as failure to do so will result in suspension of the student’s
benefit payment. This form should be returned to the VA REGIONAL OFFICE (331/21Q), 400 SOUTH 18TH STREET, ST. LOUIS, MO 63103-2271.
(NOTE: DO NOT USE "NA" OR "UNKNOWN" IN ITEMS REQUIRING COMPLETION.) IMPORTANT - THIS FORM SHOULD NOT BE RETURNED TO
THE STUDENT.

SECTION II - STUDENT CERTIFICATION
3. NAME OF SCHOOL YOU ATTENDED
DURING PERIOD(S) SHOWN IN ITEM 2

4A. HAVE YOU ATTENDED SCHOOL ON A FULL-TIME BASIS FOR
PERIOD SHOWN IN ITEM 2?
YES
NO (If "No," complete Item 5)
4B. TYPE OF DEGREE
GRAD
UNDERGRAD
OTHER

6. WILL YOU CONTINUE SCHOOL ON A FULL-TIME BASIS
AFTER THE END OF THE PERIOD SHOWN IN ITEM 2?

YES

5. LIST DATES OF FULL-TIME
ATTENDANCE IF DIFFERENT
FROM ITEM 2 (Month, day, year)

7. DATES OF YOUR NEXT SCHOOL YEAR
A. BEGINNING DATE (Month, day, year)

B. ENDING DATE (Month, day, year)

NO (If "Yes," complete Item 7)

8A. WILL YOU ATTEND THE SCHOOL SHOWN IN ITEM 3?

YES

8B. NAME AND ADDRESS OF NEW SCHOOL

8C. TYPE OF NEW SCHOOL
COLLEGE OR UNIVERSITY

NO (If "No," complete Items 8B thru 8D)

8D. TYPE OF DEGREE
GRAD

TECHNICAL, TRADE OR VOCATIONAL

UNDERGRAD

OTHER (Specify)

OTHER

9. EARNINGS/WAGES RECEIVED FOR PRIOR
YEAR (ENTER DOLLAR AMOUNT OR "NONE")
YEAR

10A. EARNINGS EXPECTED THIS YEAR
(ENTER DOLLAR AMOUNT OR "NONE")

AMOUNT

YEAR

10B. EARNINGS EXPECTED NEXT YEAR
(ENTER DOLLAR AMOUNT OR "NONE")

AMOUNT

$

YEAR

$

11. HAVE YOU OR WILL YOU BE PAID BY YOUR
EMPLOYER FOR ATTENDING SCHOOL?
YES
NO

12A. HAVE YOU EVER BEEN MARRIED?
YES

NO

AMOUNT

$
12B. DATE(S) OF MARRIAGE (Month, day, year)

(If "Yes," complete Item 12B)

IMPORTANT: IT IS YOUR DUTY TO REPORT ANY CHANGE IN STATUS. You must notify the VA immediately of any
change in school enrollment, marital or work status, as benefits may be affected.
I CERTIFY THAT the previous statements are true and correct to the best of my knowledge and belief.
13A. SIGNATURE OF CLAIMANT

13B. CLAIMANT’S TELEPHONE NUMBER (Include Area Code)

13C. DATE SIGNED (Month, day, year)

SECTION III - SCHOOL OFFICIAL CERTIFICATION
14. HAS THE STUDENT MAINTAINED
FULL-TIME STATUS BY THE SCHOOL’S
STANDARDS DURING THE ENTIRE
PERIOD SHOWN IN ITEM 2?

YES

15A. LIST DATES OF FULL-TIME ATTENDANCE, INCLUDING LAST DATE OF FULL-TIME
ATTENDANCE WHEN A COURSE WITHDRAWAL IS INVOLVED
15B. IF TERM CLAIMED IN ITEM 7 HAS BEGUN, IS STUDENT STILL FULL-TIME?

NO (If "No," complete Item 15)

YES

16A. NAME OF SCHOOL

NO

16C. TYPE OF SCHOOL
COLLEGE OR
UNIVERSITY

TECHNICAL, TRADE
OR VOCATIONAL

OTHER

17. ENTER CLOCK HOURS ATTENDED
PER WEEK IF NOT A DEGREE
GRANTING PROGRAM

16D. TYPE OF DEGREE

16B. TELEPHONE NUMBER OF SCHOOL OFFICIAL
(Include Area Code)

GRAD

UNDERGRAD

18A. SIGNATURE AND TITLE OF SCHOOL OFFICIAL

OTHER
18B. DATE SIGNED (Month, day, year)

PENALTY: The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact, knowing it to be false or
for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
JUN 2008

21-8938-1

SUPERSEDES VA FORM 21-8938-1, MAR 2004,
WHICH WILL NOT BE USED.