VA Form 22-5490 Dependents' Application for VA Education Benefits (Under Provisions of Chapters 33 and 35, of Title 38, U.s.c.)

What Is VA Form 22-5490?

VA Form 22-5490, Dependents' Application for VA Education Benefits - also known as the VA Chapter 35 Form - is a document used by veterans' spouses, dependents, and survivors to apply for the Department of Veterans Affairs (VA) educational benefits. These benefits include financial assistance and can be used toward a traditional degree, non-college degree, on-the-job training, apprenticeships, etc.

The latest version of VA 22-5490 Form was released by the VA in October 2018 with all previous editions obsolete. A VA Form 22-5490 fillable version is available for download below.

This form is related to the VA Form 22-5495, Dependents' Request for Change of Program or Place of Training. This form serves as a request to change a program or place of training under one of the following benefit programs: Survivors' and Dependents' Educational Assistance Program and Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship.

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OMB Approved No. 2900-0098
Respondent Burden: 45 minutes
Expiration Date: 10/31/2021
VA DATE STAMP
(For VA Use Only)
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(Under Provisions of chapters 33 and 35, of title 38, U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.benefits.va.gov/gibill.
Request to Opt-Out of Information Sharing With Educational Institutions
By checking the box, I CERTIFY THAT THE DEPARTMENT OF VETERANS AFFAIRS (VA) does not have my permission to share information about my veterans'
education benefits with any educational institution. I understand that sharing my information with my school is intended to support the certification process and that
"opting-out" may delay that process. See Information and Instructions on Page 7 for more information.
PART I - APPLICANT INFORMATION
3. DATE OF BIRTH
1. SOCIAL SECURITY NUMBER
2. SEX OF APPLICANT
MALE
FEMALE
(First name, middle initial, last name)
4. NAME
(Number and street or rural route, city or P.O., State and ZIP Code)
5. CURRENT MAILING ADDRESS
(Including Area Code)
6. TELEPHONE NUMBER(S)
PRIMARY
SECONDARY
7. E-MAIL ADDRESS
(Attach a voided personal check or provide the following information. See instructions for additional information.)
8. DIRECT DEPOSIT
ROUTING OR TRANSIT NUMBER
ACCOUNT TYPE
ACCOUNT NUMBER
CHECKING
SAVINGS
9. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
(Include Area Code)
C. TELEPHONE NUMBER
B. ADDRESS
A. NAME
PART II - QUALIFYING INDIVIDUAL INFORMATION
(First name, middle initial, last name)
10. NAME OF QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED
11. SOCIAL SECURITY NUMBER OR VA FILE NUMBER
13. DATE OF BIRTH
12. BRANCH OF SERVICE
14C. DATE LISTED AS MISSING IN ACTION
14A. DID PARENT OR SPOUSE DIE WHILE SERVING ON ACTIVE DUTY?
14B. DATE OF DEATH
OR P.O.W.
(If "Yes," is checked complete
(If "No," is checked then you do not qualify
YES
NO
Item 14B)
for the Fry Scholarship)
15. IS QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON ACTIVE DUTY?
YES
NO
16. DO YOU (APPLICANT) OR THE QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES
NO
PART III - RELATIONSHIP AND BENEFIT INFORMATION
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL (Check only one)
SPOUSE/SURVIVING SPOUSE
CHILD/STEPCHILD/ADOPTED CHILD
(Please complete only Section I on page 2, and then proceed to Part V)
(Please complete only Section II on page 2, and then proceed to Part V)
SECTION I - SPOUSE/SURVIVING SPOUSE
18. IS A DIVORCE OR ANNULMENT PENDING TO THE
19. IF YOU ARE THE SURVIVING SPOUSE, HAVE YOU REMARRIED?
QUALIFYING INDIVIDUAL?
(If "Yes," please provide date of remarriage)
YES
YES
NO
NO
VA FORM
SUPERSEDES VA FORM 22-5490, JUN 2017,
22-5490
PAGE 1
OCT 2018
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0098
Respondent Burden: 45 minutes
Expiration Date: 10/31/2021
VA DATE STAMP
(For VA Use Only)
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(Under Provisions of chapters 33 and 35, of title 38, U.S.C.)
INTERNET VERSION AVAILABLE - You may complete and submit your application online at: www.benefits.va.gov/gibill.
Request to Opt-Out of Information Sharing With Educational Institutions
By checking the box, I CERTIFY THAT THE DEPARTMENT OF VETERANS AFFAIRS (VA) does not have my permission to share information about my veterans'
education benefits with any educational institution. I understand that sharing my information with my school is intended to support the certification process and that
"opting-out" may delay that process. See Information and Instructions on Page 7 for more information.
PART I - APPLICANT INFORMATION
3. DATE OF BIRTH
1. SOCIAL SECURITY NUMBER
2. SEX OF APPLICANT
MALE
FEMALE
(First name, middle initial, last name)
4. NAME
(Number and street or rural route, city or P.O., State and ZIP Code)
5. CURRENT MAILING ADDRESS
(Including Area Code)
6. TELEPHONE NUMBER(S)
PRIMARY
SECONDARY
7. E-MAIL ADDRESS
(Attach a voided personal check or provide the following information. See instructions for additional information.)
8. DIRECT DEPOSIT
ROUTING OR TRANSIT NUMBER
ACCOUNT TYPE
ACCOUNT NUMBER
CHECKING
SAVINGS
9. PLEASE PROVIDE THE NAME, ADDRESS, AND TELEPHONE NUMBER OF SOMEONE WHO WILL ALWAYS KNOW WHERE YOU CAN BE REACHED
(Include Area Code)
C. TELEPHONE NUMBER
B. ADDRESS
A. NAME
PART II - QUALIFYING INDIVIDUAL INFORMATION
(First name, middle initial, last name)
10. NAME OF QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON WHOSE ACCOUNT BENEFITS ARE BEING CLAIMED
11. SOCIAL SECURITY NUMBER OR VA FILE NUMBER
13. DATE OF BIRTH
12. BRANCH OF SERVICE
14C. DATE LISTED AS MISSING IN ACTION
14A. DID PARENT OR SPOUSE DIE WHILE SERVING ON ACTIVE DUTY?
14B. DATE OF DEATH
OR P.O.W.
(If "Yes," is checked complete
(If "No," is checked then you do not qualify
YES
NO
Item 14B)
for the Fry Scholarship)
15. IS QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) ON ACTIVE DUTY?
YES
NO
16. DO YOU (APPLICANT) OR THE QUALIFYING INDIVIDUAL (PARENT OR SPOUSE) HAVE AN OUTSTANDING FELONY AND/OR WARRANT?
YES
NO
PART III - RELATIONSHIP AND BENEFIT INFORMATION
17. YOUR RELATIONSHIP TO QUALIFYING INDIVIDUAL (Check only one)
SPOUSE/SURVIVING SPOUSE
CHILD/STEPCHILD/ADOPTED CHILD
(Please complete only Section I on page 2, and then proceed to Part V)
(Please complete only Section II on page 2, and then proceed to Part V)
SECTION I - SPOUSE/SURVIVING SPOUSE
18. IS A DIVORCE OR ANNULMENT PENDING TO THE
19. IF YOU ARE THE SURVIVING SPOUSE, HAVE YOU REMARRIED?
QUALIFYING INDIVIDUAL?
(If "Yes," please provide date of remarriage)
YES
YES
NO
NO
VA FORM
SUPERSEDES VA FORM 22-5490, JUN 2017,
22-5490
PAGE 1
OCT 2018
WHICH WILL NOT BE USED.
SOCIAL SECURITY NUMBER OF APPLICANT
SECTION I - SPOUSE/SURVIVING SPOUSE (Continued)
20. SPOUSE/SURVIVING SPOUSE SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:
PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS ON PAGE 5, ITEM 20 BEFORE SELECTING BOX "A"
IMPORTANT ►
OR "B" BELOW REGARDING THE BENEFIT YOU ARE APPLYING FOR. THE INFORMATION AND INSTRUCTIONS ON PAGE 5
ALSO PROVIDE LINKS TO VA WEBSITES WHERE YOU WILL BE ABLE TO COMPARE "DEA" AND "FRY" BENEFITS. YOU
WILL ALSO FIND OTHER ELIGIBILTIY RELATED INFORMATION THERE.
AS A SPOUSE OR SURVIVING SPOUSE BASED ON 100%
AS A SURVIVING SPOUSE BASED ON LINE OF DUTY
A.
B.
PERMANENT AND TOTAL DISABILITY, SERVICE CONNECTED
DEATH AFTER SEPTEMBER 10, 2001, I AM APPLYING
OR LINE OF DUTY DEATH, I AM APPLYING FOR
FOR CHAPTER 33 - FRY SCHOLARSHIP BENEFITS.
CHAPTER 35 - DEA BENEFITS.
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
SECTION II - CHILD/STEPCHILD/ADOPTED CHILD
21. CHILD/STEPCHILD/ADOPTED CHILD SELECT THE BENEFIT THAT YOU ARE APPLYING FOR BELOW:
PLEASE CAREFULLY READ THE INFORMATION AND INSTRUCTIONS ON PAGE 6, ITEM 21 BEFORE SELECTING BOX "A"
IMPORTANT ►
OR "B" BELOW REGARDING THE BENEFIT YOU ARE APPLYING FOR. THE INFORMATION AND INSTRUCTIONS ON PAGE 5
ALSO PROVIDE LINKS TO VA WEBSITES WHERE YOU WILL BE ABLE TO COMPARE "DEA" AND "FRY" BENEFITS. YOU
WILL ALSO FIND OTHER ELIGIBILTIY RELATED INFORMATION THERE.
I AM APPLYING FOR CHAPTER 35 - DEA BENEFITS.
I AM APPLYING FOR CHAPTER 33 - FRY SCHOLARSHIP
A.
B.
BENEFITS.
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
NOTE - BY CHECKING THIS BOX I ACKNOWLEDGE THAT I UNDERSTAND
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
THIS ELECTION IS IRREVOCABLE AND MAY NOT BE CHANGED.
Important - If your parent died in the line of duty prior to August 1, 2011, you
Important - If your parent died in the line of duty prior to August 1, 2011, you
may apply for both DEA and Fry Scholarship benefits.
may apply for both DEA and Fry Scholarship benefits.
If you are eligible for both Chapter 35 (DEA) and Chapter 33 (Fry Scholarship)
If you are eligible for both Chapter 35 (DEA) and Chapter 33 (Fry Scholarship) benefits
benefits and you would like to use the Chapter 33 benefit first, check the box below.
and you would like to use the Chapter 35 benefit first, check the box below.
CHAPTER 33 - FRY SCHOLARSHIP
CHAPTER 35 - DEA
IMPORTANT: If you are over the age of 18 once you receive either the DEA or FRY SCHOLARSHIP benefits, you will no longer receive payments of Dependency
and Indemnity Compensation (DIC) or Pension and you may no longer be claimed as a dependent in a Compensation claim. If you are under the age of 18, on your 18th
birthday you will lose eligibility for DIC or Pension payments and you will no longer be claimed as a dependent in a Compensation claim.
CAREFULLY READ THE INFORMATION AND INSTRUCTIONS ON PAGE 6, ITEM 22 BEFORE COMPLETING THE ELECTION BOX BELOW.
YOU ARE STRONGLY ENCOURAGED TO DISCUSS YOUR ELECTION WITH A VA COUNSELOR.
22. I CERTIFY THAT I UNDERSTAND THE EFFECTS THAT THIS ELECTION TO RECEIVE DEA OR FRY SCHOLARSHIP BENEFITS WILL HAVE ON MY ELIGIBILITY
TO RECEIVE DIC OR PENSION BENEFITS (Please read Information and Instructions Page 6 for additional information)
YES
NO
PART IV - BENEFIT AND TYPE OF EDUCATION OR TRAINING INFORMATION
DATE YOU WILL BEGIN SCHOOL OR TRAINING (MM/DD/YYYY)
23A.
TYPE OF EDUCATION OR TRAINING (Check ONE box)
23B.
COLLEGE OR OTHER SCHOOL
FARM COOPERATIVE
LICENSING OR CERTIFICATION TEST
APPRENTICESHIP OR OTHER ON-THE-JOB TRAINING
NATIONAL ADMISSION EXAMS OR NATIONAL EXAMS FOR CREDIT
CORRESPONDENCE COURSE
FLIGHT TRAINING (Fry Scholarship only)
DEA ONLY] DO YOU HAVE A MENTAL OR PHYSICAL
DEA ONLY] DO YOU HAVE A MENTAL OR PHYSICAL DISABILITY FOR
23D. [
23C. [
DISABILITY FOR WHICH YOU ARE SEEKING SPECIAL
WHICH YOU ARE SEEKING SPECIAL RESTORATIVE TRAINING?
VOCATIONAL TRAINING? (See Information and Instructions,
(See Information and Instructions, Page 6, for details regarding restorative training)
Page 6, for details regarding special vocational training)
YES
YES
NO
NO
PAGE 2
VA FORM 22-5490, OCT 2018
SOCIAL SECURITY NUMBER OF APPLICANT
(Number and street or rural route, city or P.O., State and ZIP Code)
24. NAME AND ADDRESS OF SCHOOL OR TRAINING FACILITY
25. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE, IF KNOWN (e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)
(See Information and Instructions, Item 26 for more information regarding
26. WOULD YOU LIKE TO RECEIVE VOCATIONAL AND EDUCATIONAL COUNSELING?
vocational and educational counseling)
YES
NO
PART V - APPLICATION HISTORY
(Check all appropriate boxes)
27. PRIOR TO THIS APPLICATION, HAVE YOU EVER APPLIED FOR OR RECEIVED ANY OF THE FOLLOWING VA BENEFITS?
A.
DISABILITY COMPENSATION OR PENSION
(DIC)
B.
DEPENDENTS' INDEMNITY COMPENSATION
(Chapter 31)
C.
VOCATIONAL REHABILITATION BENEFITS
D.
VETERANS EDUCATION ASSISTANCE BASED ON YOUR OWN SERVICE (Specify benefit(s):
E.
VETERANS EDUCATION ASSISTANCE BASED ON SOMEONE ELSE'S SERVICE
SPECIFY BENEFIT(S) BY CHECKING APPLICABLE BOX BELOW AND COMPLETE ITEMS 28 AND 29
TRANSFERRED ENTITLEMENT
(DEA)
CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE PROGRAM
CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY SERGEANT DAVID FRY SCHOLARSHIP
F.
NONE
G.
OTHER (Specify benefit(s):
IMPORTANT: Complete Items 28 and 29 only if you checked the box for Item 27E above.
(First, Middle, Last)
28. NAME OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS
29. SOCIAL SECURITY NUMBER OF INDIVIDUAL ON WHOSE ACCOUNT YOU PREVIOUSLY CLAIMED BENEFITS
PART VI - APPLICANT'S MILITARY SERVICE INFORMATION
(NOTE: Chapter 35 benefits are not payable while an eligible person is on active duty)
(If "No," skip to Part VII)
30. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE ARMED FORCES?
YES
NO
31. INFORMATION ABOUT YOUR PERIOD(S) OF ACTIVE DUTY (If you need additional space use Item 37, Remarks)
B. DATE SEPARATED
C. BRANCH OF SERVICE OR
A. DATE ENTERED ACTIVE DUTY
D. CHARACTER OF DISCHARGE
FROM ACTIVE DUTY
RESERVE OR GUARD COMPONENT
PART VII - EDUCATION, TRAINING AND EMPLOYMENT
SECTION I - EDUCATION & TRAINING
32. CHECK THE APPROPRIATE BOX AND ENTER THE DATE IN ITEM 33
33. DATE
NEVER ATTENDED
GRADUATED FROM HIGH SCHOOL
DISCONTINUED HIGH SCHOOL
HIGH SCHOOL
EXPECT TO GRADUATE FROM HIGH SCHOOL
AWARDED GED
34B. NAME AND LOCATION
34C. DATES OF TRAINING
34E. DEGREE, DIPLOMA
34D. NUMBER OF
34A. TYPE
34F. MAJOR FIELD OR
OF SCHOOL
OR CERTIFICATE
SEMESTER, QUARTER, OR
OF SCHOOL
COURSE OF STUDY
FROM
TO
CLOCK HOURS COMPLETED
(City and State)
RECEIVED
HIGH SCHOOL
COLLEGE
VOCATIONAL
OR TRADE
OTHER
(Specify)
PAGE 3
VA FORM 22-5490, OCT 2018
SOCIAL SECURITY NUMBER OF APPLICANT
PART VII - EDUCATION, TRAINING AND EMPLOYMENT (Continued)
SECTION II - EMPLOYMENT
35. CURRENT AND PAST EMPLOYMENT
C. NUMBER OF MONTHS
A. EMPLOYER
D. LICENSE OR RATING
B. JOB TITLE
EMPLOYED
NOTE: Complete Items 36A and 36B only if you are a civilian employee of the U.S. Government.
36B. SOURCE OF EDUCATIONAL ASSISTANCE FROM GOVERNMENT
36A. DO YOU EXPECT TO RECEIVE FUNDS FROM YOUR AGENCY OR
EMPLOYMENT
DEPARTMENT FOR THE SAME COURSES FOR WHICH YOU EXPECT TO
(If "Yes," complete Item 36B)
RECEIVE VA EDUCATIONAL ASSISTANCE?
YES
NO
PART VIII - REMARKS, REMINDERS AND VA EDUCATION BENEFITS PAMPHLET
SECTION I - REMARKS
(If more space is needed, please attach a separate sheet of paper. Be sure to include name and social security number on each sheet)
37. REMARKS
SECTION II - REMINDERS
DID YOU REMEMBER TO:
• WRITE YOUR SOCIAL SECURITY NUMBER ON EACH PAGE
• WRITE YOUR COMPLETE MAILING ADDRESS
• ATTACH SUPPORTING DOCUMENTS (e.g., birth certificate, marriage license, DD214, etc.)
SECTION III - VA EDUCATION BENEFITS PAMPHLET
38. THE MOST CURRENT INFORMATION ON VA EDUCATION BENEFITS IS AVAILABLE ONLINE AT www.benefits.va.gov/gibill. IF YOU WOULD LIKE A COPY OF THE
VA EDUCATION BENEFITS PAMPHLET PLEASE CHECK THE BOX.
PART IX - CERTIFICATION AND SIGNATURE OF APPLICANT
I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.
(DO NOT PRINT)
39B. DATE SIGNED
39A. SIGNATURE OF APPLICANT
SIGN HERE ►
IN INK
PENALTY: Willfully 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.
PART X - SIGNATURE OF PARENT, GUARDIAN OR CUSTODIAN
(This section must be completed by the parent, guardian, or custodian if the applicant is a minor)
40. NAME OF PARENT, GUARDIAN, OR CUSTODIAN (First, Middle Initial, Last) (Type or print)
41. MAILING ADDRESS OF PARENT, GUARDIAN, OR CUSTODIAN
Number and Street
Apt./Unit Number
City, State, ZIP Code
42A. TELEPHONE NUMBER(S) OF PARENT, GUARDIAN, OR CUSTODIAN (Include Area Code)
Primary:
Secondary:
42B. E-MAIL ADDRESS OF PARENT, GUARDIAN, OR CUSTODIAN (If applicable)
(Check one)
43A. SIGNATURE OF:
43B. DATE SIGNED
SIGN HERE ►
IN INK
PARENT
GUARDIAN
CUSTODIAN
(DO NOT PRINT)
PAGE 4
VA FORM 22-5490, OCT 2018
(Please retain these Information and Instructions Pages for future reference)
INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
DEPENDENTS' APPLICATION FOR VA EDUCATION BENEFITS
(VA FORM 22-5490)
Do not use this form to apply for Veterans' education assistance based on your own service (chapters 30, 32, 33, 1606, or
1607) or vocational rehabilitation benefits (chapter 31). To apply for veterans' education assistance based on your own
service, use VA Form 22-1990. To apply for vocational rehabilitation benefits, use VA Form 28-1900. VA forms are
available at www.va.gov/vaforms.
INTERNET VERSION AVAILABLE - You may complete and submit this application on-line at www.benefits.va.gov/gibill. Click on "GI
Bill: Apply for Benefits."
NOTE: The numbers on these Information and Instructions pages match the item numbers on this application. Items not mentioned are
self-explanatory.
ITEM 8. The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit.
Please attach a voided personal check or deposit slip or provide the information requested below to enroll in direct deposit. If you do not have a bank
account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard, you must apply at
www.usdirectexpress.com
or by telephone at 1-800-333-1795. If you elect not to enroll, you must contact representatives handling waiver requests
for the Department of Treasury at 1-888-224-2950. They will address any questions or concerns you may have and encourage your participation in
EFT.
ITEM 16. You will not be eligible to receive benefits for any period for which you or the qualifying individual on whose account you are claiming benefits
has an outstanding felony warrant. Any benefits paid to you for such period will result in an overpayment and be subject to collection.
ITEM 17. If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your
spouse resided at the time of marriage or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for
benefits) (38 U.S.C.§ 103(3)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
ITEM 20. IMPORTANT - PLEASE READ THE INFORMATION BELOW BEFORE MAKING YOUR SELECTION IN ITEM 20A OR 20B REGARDING
THE BENEFIT YOU ARE APPLYING FOR.
To qualify for the Post-9/11 GI Bill Marine Gunnery Sergeant John David Fry Scholarship, you must be the surviving spouse of an
individual who died in the line of duty while serving on active duty as a member of the Armed Forces after September 10, 2001.
To qualify for Survivor's and Dependents' Educational Assistance (DEA) you must be either:
(1) The spouse of a veteran who is permanently and totally disabled as a result of a service-connected disability, OR
(2) The spouse of an individual on active duty who has been listed as missing in action, captured in the line of duty by
hostile force, forcibly detained or interned in the line of duty by hostile force, or forcibly detained or interned in the line of duty by
a foreign government or power for more than 90 days, OR
(3) The surviving spouse or child of a veteran who died of a service-connected disability or who dies while a service-connected disability
was rated permanent and total in nature, OR
(4) The surviving spouse of an individual on active duty for which the evidence shows that the individual is hospitalized for receiving
outpatient medical care services or treatment; has a total disability permanent in nature incurred or aggravated in the line of duty
in the active military, naval, or air service; and the service person is likely to be discharged or released from such service for such disability.
NOTE: If you are eligible for both Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA) and Chapter 33 Post-9/11 GI Bill
Marine Gunnery Sergeant John David Fry Scholarship (Fry Scholarship) benefits, you must relinquish/give up entitlement to one or the other benefit for
which you are eligible, even if entitlement arises from separate events. In other words, you must forfeit eligibility to the other benefit even if your
eligibility is due to:
• A separate Period of Service (POS) other than the one for which the death of the spouse is associated; OR
• A separate POS other than the one for which your spouse has a total disability permanent in nature resulting
from a service-connected disability; OR
• A separate POS based on any other criteria as listed in 38 U.S.C. § 3501(a)(1); OR
• Death of any other individual identified in Item 10 of this application.
IMPORTANT: You cannot retain eligibility for both programs simultaneously. Therefore, by checking either box "A" or box "B" in Item 20, you agree and
understand that you are making an irrevocable election to receive the selected benefit and your election may not be changed.
IMPORTANT: Eligibility for (DEA) will be terminated in the event that VA determines that the individual on whose account benefits are claimed is no
longer totally disabled or VA is notified that the individual is no longer listed as captured, missing in action, or forcibly detained.
Note: Before making your election selection, you can compare the differences between (DEA) and (FRY), and the benefits each provide in order
to help you make the best choice that suits your needs.This benefit comparison information can be found on the VA website at:
https://www.benefits.va.gov/gibill/docs/factsheets/fry_scholarship.pdf. You can also find additional information about each program by visiting the
GI Bill website at:
https://benefits.va.gov/gibill/
and using the comparison tool.
VA FORM 22-5490, OCT 2018
PAGE 5

Download VA Form 22-5490 Dependents' Application for VA Education Benefits (Under Provisions of Chapters 33 and 35, of Title 38, U.s.c.)

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What to Submit with VA Form 22-5490?

The application should be submitted with supporting documents, providing backup and depth to the information on the form. These papers include the following:

VA Form 22-5490 Instructions

The VA Form 22-5490 is made up of eight pages with general information and filling guidelines provided on the last three pages. The instructions for completing the form are below.

How to Fill out VA Form 22-5490?

The VA Form 22-5490 consists of 10 parts:

  1. Section I. Applicant Information. Enter your personal identification information and contact information, as well as the direct deposit data and name, phone and address of an emergency contact.
  2. Section II. Qualifying Individual Information. This section is for the personal information about the person, on whose behalf the benefits are claimed. Provide their name, enter their SSN or VA file number, their date of death, if applicable. This part also requires the information, whether the qualifying individual is on active duty and if they or the applicant has a warrant or an outstanding felony.
  3. Section III. Relationship and Benefits Information, contain two sections. Section I should be filled if you are a spouse of the qualifying individual. If you are a child of a qualifying individual, fill out Section II.
  4. Section IV. Benefit and Type of Education or Training Information. Enter information regarding the education or training you are claiming. This part should also include information, whether the applicant has a disability, that requires restorative or vocational training.
  5. Section V. Application History. Fill out this section if you have ever applied for any VA benefit programs.
  6. Section VI. Applicant's Military Service Information. Fill out this section if you have ever served on active duty in the armed forces and provide information about the service.
  7. Section VII. Education, Training and Employment Information. Enter information about your school, current and past employment.
  8. Section VIII. Remarks, Reminders and VA Education Benefits. This section provides for additional remarks. This part can be also used to request a copy of the VA Education Benefits Pamphlet.
  9. Section I. Certification and Signature of Applicant. By signing and dating the form you certify that all information provided is true and correct.
  10. Section X. Signature of Parent, Guardian or Custodian. Fill out this section if you are a minor. Enter your name, mailing address, phone number, email address, and status. Sign and date the form.

Where to Mail VA Form 22-5490?

  • If you have selected a school or training establishment, mail the completed application to the VA Regional Processing Office for the region of that school's physical address;
  • If you have not selected a school or training establishment, mail the completed application to the VA Regional Processing Office in your area of residence;
  • The form can be completed and submitted online using the VA website.
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