Request for Certification of VA Benefits VA Certification Request Form - Must be submitted each semester Semester(Required)FallSpringSummerYear(Required)202320242025STUDENT INFORMATIONName(Required) First Last Student ID(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) PROGRAM OF STUDYMajor(Required) Expected Graduation Date(Required) Changed Major? Please check this box if you have changed your major from a prior semester. CURRENT VA STATUSCurrent VA Status(Required) New VA Claimant Continuing Student Transfer Student Guest Student (Permission to enroll at another Institution required) TYPE OF VA BENEFITS REQUESTEDChapter 33 (Post 9/11 GI Bill) I am a Veteran/Service Member I am a Dependent of the Veteran/Service Member Chapter 30 (Montgomery GI Bill) Active Duty Veteran Chapter 31 (Vocational Rehabilitation) Chapter 31 Please check with your VA Counselor for course approvalChapter 35 (Survivors & Dependents Educational Assistance) Chapter 35 Chapter 1606/1607 (Active Selected Reserves/National Guard) Chapter 1606/1607 Tuition Assistance TA/MYCAA Air Force Air National Guard Army Army National Guard Coast Guard Marines Navy I am a Service Member I am a Service Member's spouse I am requesting a TA Agreement STUDENT ACCOUNTABILITY I am responsible for payment of all tuition and fees that my VA benefits do not cover. I understand that I must immediately notify the One Stop Coordinator – Veterans Affairs of any changes made to my class schedule by me or anyone else under any circumstances (i.e. adds, drops, withdrawals, change of major, etc.). Failure to notify the One Stop Coordinator – Veterans Affairs may result in an overpayment of VA Benefits. I understand that I am responsible for all debts resulting from reductions or terminations of my enrollment even if the payment was submitted directly to the college on my behalf. I understand that I must attend all classes to the end of the term. I understand that I must submit transcript(s) from prior colleges/universities and military schools for evaluation. I understand that the VA will only pay for classes required for my degree plan. Each semester, the VA Certifying Official verifies all veteran registered classes to confirm each class is required for that student’s degree plan. I must notify the VA Certifying Official of any change to my degree plan within 24-hours of a change being made.Acknowledgement of Student Accountability(Required) Acknowledgement of Student Accountability Please check the box acknowledging that you have read and understand the information listed in the Student Accountability sectionSignature(Required)Date(Required) MM slash DD slash YYYY Please upload supplemental documentation here Drop files here or Select files Max. file size: 50 MB. Certificate of Eligibility, Latest Degree Audit, etc.NOTICE OF PUBLIC LAW 115-407, SECTIONS 103 AND 104In accordance with the Veterans Benefits and Transition Act of 2018, section 3679(e) of title 38 (Public Law 115-407), a student who is entitled to educational assistance under Chapter 31, Vocational Rehabilitation & Employment, or Chapter 33, Post-9/11 GI Bill benefits shall be permitted to attend or participate in the course of education during the period beginning on the date on which the individual provides to the educational institution a Certificate of Eligibility for entitlement to educational assistance under Chapter 31 or 33 (a “Certificate of Eligibility” can also include a “Statement of Benefits” obtained from the Department of Veterans Affairs’ website – eBenefits, or a VAF 28-1905 form for Chapter 31) and ending on the earlier of the following dates: The date on which payment from VA is made to the institution. 90 days after the date the institution certified tuition and fees following the receipt of the Certificate of Eligibility The University shall not impose any penalty, including the assessment of late fees, the denial of access to classes, libraries, or other institutional facilities, or require the student to borrow additional funds, in order to meet his or her financial obligations to the institution due to the delayed disbursement funding from VA under Chapter 31 or 33.
