Certification Request for VA Educational Benefits


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Name (First, Middle, Last) SSN Student ID


Mailing Address Primary phone DOB


City State Zip Email:


Chapter 30 (MGIB) Chapter 31 (Voc Rehab) Chapter 33 (Post 9/11) Chapter 1607 (REAP) Chapter 1606(Guard/Reservist)

Chapter 33 (Post 9/11) transferability


Chapter 35 (DEA) (VA Claim # /Child # )


First Time Using Benefits? Yes No If no, previous school:


Program of Study: (Ex: BA/History)


Yellow Ribbon (Chapter 33 only) Out of state residency


100% eligibility rating Active duty status

YES NO

YES NO

YES NO


Choice Act (Chapter 33 only)


ETS Service within 3 years of starting school

Submitted DD214 for verification

ETS date (DD214):

NOT Active Duty


Tuition Assistance (Chapter 1606 only):

Will be receiving TA and understand I will not be eligible for GI Bill benefits and/ or TA may affect my tuition and fee payment under Post 9/11 Chapter 33



Signature:


Date: