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Download VA Form 21-674B "School Attendance Report"

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OMB Approved No. 2900-0049
Respondent Burden: 5 minutes
Expiration Date: 06/30/2021
1. VA FILE NUMBER
SCHOOL ATTENDANCE REPORT
C/CSS -
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 (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United
States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, and published in
the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is considered relevant and necessary to determine maximum benefits under
the law. Giving us your and your dependents' SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are
claimed under Title 38 U.S.C. 5101(c)(1). 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. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer
matching programs with other agencies.
Respondent Burden: We need this information to determine entitlement to benefits for a veteran's child who is between age 18 and 23 and attending school (38 U.S.C. 104(a)). Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 5 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on
where to send comments or suggestions about this form.
2. VA OFFICE TO WHICH THIS FORM SHOULD BE RETURNED
3A. FIRST, MIDDLE, LAST NAME OF VETERAN
(If applicable)
3B. E-MAIL ADDRESS OF VETERAN
4A. FIRST, MIDDLE, LAST NAME OF STUDENT
4B. SOCIAL SECURITY NUMBER OF STUDENT
INSTRUCTIONS: Complete either Part I or Part II, and return the completed form to the VA office shown in Item 2.
PART I - VERIFICATION OF SCHOOL ATTENDANCE
(To Be Completed By Claimant)
Benefits have been awarded because the student named in Item 4 expects to start a course of training. Complete Part I, and return this form to the VA
office shown in Item 2 within 60 days after the date the student begins the course. If the form is not returned, benefits paid based on school
attendance will be discontinued.
NOTE: The form will be signed by the student only if he or she has reached the age of majority and is receiving benefits in his or her own right. The
age of majority is determined by State law; it is age 18 in most States. Otherwise, the parent, guardian, or custodian will sign and also enter his or her
relationship to the student in Item 8.
5. OFFICIAL BEGINNING DATE OF REGULAR
6A. DID STUDENT START THE COURSE OF TRAINING?
6B. DATE STUDENT STARTED COURSE OF
(Month, day,year)
(Month, day, year)
TERM OF COURSE
TRAINING
(If "Yes," complete Item 6B)
YES
(If "No," enter reason in Item 15)
NO
7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID UNDER VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA),
FEDERAL EMPLOYEES' COMPENSATION ACT OR ANY OTHER FEDERAL AGENCY BENEFIT (U.S. SERVICE ACADENY, U.S. MERCHANT MARINE ACADEMY,
BUREAU OF INDIAN AFFAIRS, ETC.) OF THE UNITED STATES GOVERNMENT?
(If "Yes," complete Items 7B and 7C)
YES
NO
7B. TYPE OF BENEFIT
7C. DATE PAYMENTS BEGAN
I CERTIFY THAT
the foregoing statements are true and correct to the best of my knowledge and belief.
(Sign in ink)
10. DATE SIGNED
8. SIGNATURE
9. RELATIONSHIP TO STUDENT
(Including Area Code)
(Including Area Code)
11A. DAYTIME TELEPHONE NUMBER
11B. EVENING TELEPHONE NUMBER
PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE
(To Be Completed By School)
Information has been received that the student named in Item 4 discontinued his or her course of training at your school. Please complete Items 12
through 18 and return this form to the VA office shown in Item 2.
(Month, day, year)
12A. DATE SCHOOL ATTENDANCE TERMINATED
12B. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?
(If "Yes," complete Item 13A)
(If "No," complete Item 13B)
YES
NO
13A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING
(Month, day, year)
13B. OFFICIAL ENDING DATE OF REGULAR TERM
(Month, day, year)
THE DATE STUDENT DISCONTINUED SCHOOL
14. REASON FOR TERMINATION OF ATTENDANCE
SUPERSEDES VA FORM 21-674b, APR 2015,
VA FORM
21-674b
JUN 2018
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0049
Respondent Burden: 5 minutes
Expiration Date: 06/30/2021
1. VA FILE NUMBER
SCHOOL ATTENDANCE REPORT
C/CSS -
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 (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United
States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, and published in
the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is considered relevant and necessary to determine maximum benefits under
the law. Giving us your and your dependents' SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are
claimed under Title 38 U.S.C. 5101(c)(1). 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. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer
matching programs with other agencies.
Respondent Burden: We need this information to determine entitlement to benefits for a veteran's child who is between age 18 and 23 and attending school (38 U.S.C. 104(a)). Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 5 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on
where to send comments or suggestions about this form.
2. VA OFFICE TO WHICH THIS FORM SHOULD BE RETURNED
3A. FIRST, MIDDLE, LAST NAME OF VETERAN
(If applicable)
3B. E-MAIL ADDRESS OF VETERAN
4A. FIRST, MIDDLE, LAST NAME OF STUDENT
4B. SOCIAL SECURITY NUMBER OF STUDENT
INSTRUCTIONS: Complete either Part I or Part II, and return the completed form to the VA office shown in Item 2.
PART I - VERIFICATION OF SCHOOL ATTENDANCE
(To Be Completed By Claimant)
Benefits have been awarded because the student named in Item 4 expects to start a course of training. Complete Part I, and return this form to the VA
office shown in Item 2 within 60 days after the date the student begins the course. If the form is not returned, benefits paid based on school
attendance will be discontinued.
NOTE: The form will be signed by the student only if he or she has reached the age of majority and is receiving benefits in his or her own right. The
age of majority is determined by State law; it is age 18 in most States. Otherwise, the parent, guardian, or custodian will sign and also enter his or her
relationship to the student in Item 8.
5. OFFICIAL BEGINNING DATE OF REGULAR
6A. DID STUDENT START THE COURSE OF TRAINING?
6B. DATE STUDENT STARTED COURSE OF
(Month, day,year)
(Month, day, year)
TERM OF COURSE
TRAINING
(If "Yes," complete Item 6B)
YES
(If "No," enter reason in Item 15)
NO
7A. IS TUITION AND/OR ALLOWANCE FOR STUDENT'S EDUCATION OR TRAINING BEING PAID UNDER VA DEPENDENTS' EDUCATIONAL ASSISTANCE (DEA),
FEDERAL EMPLOYEES' COMPENSATION ACT OR ANY OTHER FEDERAL AGENCY BENEFIT (U.S. SERVICE ACADENY, U.S. MERCHANT MARINE ACADEMY,
BUREAU OF INDIAN AFFAIRS, ETC.) OF THE UNITED STATES GOVERNMENT?
(If "Yes," complete Items 7B and 7C)
YES
NO
7B. TYPE OF BENEFIT
7C. DATE PAYMENTS BEGAN
I CERTIFY THAT
the foregoing statements are true and correct to the best of my knowledge and belief.
(Sign in ink)
10. DATE SIGNED
8. SIGNATURE
9. RELATIONSHIP TO STUDENT
(Including Area Code)
(Including Area Code)
11A. DAYTIME TELEPHONE NUMBER
11B. EVENING TELEPHONE NUMBER
PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE
(To Be Completed By School)
Information has been received that the student named in Item 4 discontinued his or her course of training at your school. Please complete Items 12
through 18 and return this form to the VA office shown in Item 2.
(Month, day, year)
12A. DATE SCHOOL ATTENDANCE TERMINATED
12B. IS THIS THE OFFICIAL ENDING DATE OF REGULAR TERM FOR SUCH COURSE?
(If "Yes," complete Item 13A)
(If "No," complete Item 13B)
YES
NO
13A. BEGINNING DATE OF THE NEXT REGULAR TERM FOLLOWING
(Month, day, year)
13B. OFFICIAL ENDING DATE OF REGULAR TERM
(Month, day, year)
THE DATE STUDENT DISCONTINUED SCHOOL
14. REASON FOR TERMINATION OF ATTENDANCE
SUPERSEDES VA FORM 21-674b, APR 2015,
VA FORM
21-674b
JUN 2018
WHICH WILL NOT BE USED.
(Continued)
PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE
(To Be Completed By School)
15. REMARKS
I CERTIFY THAT
the foregoing statements are true and correct to the best of my knowledge and belief.
16. NAME OF SCHOOL
(Sign in ink)
17B. TITLE OF SCHOOL OFFICIAL
18. DATE
17A. SIGNATURE OF SCHOOL OFFICIAL
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statements or evidence of a material fact,
knowing it to be false.
Page 2
VA FORM 21-674b, JUN 2018