VA FM 22-1919 - CONFLICTING INTERESTS CERT..PDF

CONFLICTING INTERESTS CERTIFICATION FOR PROPRIETARY SCHOOLS ONLY
1. NAME AND ADDRESS OF INSTITUTION
PURPOSE: This form informs individuals that the law has restrictions concerning any potential conflict of
interests. (See certifications (1) and (2) below). These certifications not only apply to chapters 31 and 36 of
Title 38, U.S.C., but also apply to the following programs administered by the Department of Veterans Affairs
(VA):
MGIB Montgomery GI Bill-Active Duty Educational Assistance Program
(Chapter 30 of Title 38, U.S.Code)
VEAP Veterans’ Educational Assistance Program (Chapter 32 of Title 38, U.S.Code)
DEA Dependents’ Educational Assistance (Chapter 35 of Title 38, U.S.Code)
MGIB-SR Montgomery GI Bill-Selected Reserve Educational Assistance Program
EAPP Educational Assistance Pilot Program (Section 903 of Public Law 96-342)
(1) PROPRIETARY PROFIT SCHOOLS ONLY
The law prohibits employees of VA and the State Approving Agency (SAA) from owning any interest in an educational institution
operated for profit. In addition, the law prohibits these employees from receiving any wages, salary, dividends, gifts, or services
from private profit schools. These provisions may be waived if VA determines that no detriment will result to the government, or to
veterans or eligible persons enrolled (38 U.S.C. 3683). Please list below those VA and SAA employees known by you who may
have a potential conflict of interest under this provision. If there are none, please enter the word "none."
NAME AND TITLE OF EMPLOYEES(S) DESCRIPTION OF ASSOCIATION WITH SCHOOL
(2) ALL PROPRIETARY SCHOOLS
38 C.F.R. 21.4202(C) prohibits the approval of any veteran or eligible person in any proprietary school of which the veteran or
trainee is an official authorized to sign certificates of enrollment or verifications/certifications of attendance, an owner or an officer.
Please list below the names and VA file numbers (claim or Social Security Numbers) of any certifying officials, owners or officers
of your school who receive VA educational assistance based on an enrollment in your school. If there are none, please enter the
word "none."
NAME AND TITLE OF EMPLOYEE(S) VA FILE NUMBER
DATES OF ENROLLMENT WITH YOUR SCHOOL
FROM TO
I DO HEREBY CERTIFY that the entries above are true and correct to the best of my knowledge. I agree to immediately notify
VA of any potential violations of the above prohibitions.
SIGNATURE OF PRESIDENT OR CHIEF ADMINISTRATIVE OFFICIAL OR SCHOOL TITLE DATE
VA FORM 22-1919 EXISTING STOCKS OF VA FORM 22-1919, MAY 1991,
JUL 1995 WILL BE USED.