Va Benefit Certification Request Form (Page 2 of 9) in pdf

PERC:____________

Date/Initial

VA BENEFIT CERTIFICATION REQUEST FORM

COURSE/PROGRAM INFORMATION

I have registered for credit/non-credit classes for the following term:

FALL 20______ SPR 20______ SUM 20______

My current Academic Program:

____________________________________________________________________________

Chapters 30, 35, 1606 and 1607 MUST pay tuition or setup a payment plan BEFORE your classes can be CERTIFIED

Effective Summer 2010: Department of VA policies declare that online remedial courses are non-certifiable.

STUDENT INFORMATION (Please Print Clearly)

Name: (Last, First, Middle)___________________________________________________________________________

SSN #________________________________________ Student ID #________________________________________

E-mail Address: ____________________________________________ Telephone: _____________________________

Last term VA Benefit was used:

FALL ________ SPRING _________ SUMMER __________

BROOKHAVEN COLLEGE

Parent Institution

OTHER :_____________________________

(Circle One):

Financial Aid: Have you received a FA Award Letter outlining your eligibility for financial aid from DCCCD? Y

VA BENEFIT: CH 30_____ CH 31 ____ CH 33 _____(_______%) CH 35 _____ CH 1606 ______ CH 1607 _____

Montgomery

Vocational

Post 9/11 GI Bill

Dependent/

Selected Reserve

REAP

Survivor

GI Bill

Rehab.

TX BENEFIT:

HAZLEWOOD ______

HAZLEWOOD LEGACY ______

ONLY the courses that apply to my current degree plan filed with the Dept of Veterans Affairs will be certified. If I take a course(s)

that is hosted by a DCCCD college that is not my parent institution, it is my responsibility to follow up with that institution concern-

ing my certification status. I understand that BHC VA Office processing time is a minimum of 2 to 4 weeks. I have attached a copy of

my PAID registration receipt (if applicable).

Signature of Applicant: _________________________________________________________ Date: _________________________

VA “ROUND OUT” Semester Certification Statement

I would like to use (semester/year) _____________________ as my VA “Round Out” semester. A VA student can round out a

schedule with non-required courses to bring her/his course load up to a full-time status in her/his last term ONLY. This allows a

student to continue to receive benefits at the full-time rate in their last term of enrollment, even though fewer credits are re-

quired to complete the program. (SCO Handbook 3rd edition pg. 48)

Signature ___________________________________________________________________ Date: __________________________

Va Benefit Certification Request Form Page 2

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