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Data Form - Va Benefits Application Form

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DATA Form

Veterans Affairs

Office of Financial Aid Wood Support Service – 116

LAST NAME

FIRST NAME

STUDENT ID (ECSU)

MAILING ADDRESS

ZIPCODE

CITY/STATE

SSN#

HOME PHONE

CELL PHONE

MAJOR

Before submitting this form, you must:



First time using GI Bill benefits: Apply online using VONAPP



For dependents using Chapter 33: Apply online using VONAPP and submit a screenshot showing approval of the Transfer

Entitlement Benefit (TEB).



First time as ECSU student, but has previously used GI Bill benefits: Apply online for change of program and place of

training.



Be registered for classes and matriculating towards a degree. (BGS please provide a copy of your degree plan).



Review your coursework to ensure classes apply to your degree. Contact your advisor with questions concerning

applicability because only applicable coursework will be certified for VA benefits.

Please submit, with this form, a copy of your Certificate of Eligibility (COE), NOBE, or DD-214 (member 4) and CT Driver’s

License or proof of residency if applying for CT Veterans Waiver.

Benefit information (select one)

Ο Chapter 30 (Active Duty) – Montgomery GI Bill

Ο Chapter 30 (Veteran) Montgomery GI Bill– Are you using Ct Tuition Waiver also Yes __ No __

Ο Chapter 31 – Vocational Rehab (VA Counselor must submit 1905)

Ο Chapter 33 (Active Duty) – Post 9/11 GI Bill

Ο Chapter 33 (Veteran) Post 9/11 GI Bill - Are you using Ct Tuition Waiver also Yes __

No __

Ο Chapter 33 (Spouse/dependent –transfer of benefits) Post 9/11 GI Bill CT Waiver does not apply

Ο Chapter 35 – Dependent/Survivor (Federal Benefit Only) – Enter VA Claim # ____________________________

Ο Chapter 1606 – Reserve (training)

Ο Chapter 1607 – Reserve (deployed)

Ο CT Tuition Waiver only

Ο Yellow Ribbon

Ο I wish to waive Eastern sickness insurance (if not needed) deadline 9/15 and 2/15. E-web, student services,

student account, student insurance waiver.

I have read the information contained in this form, including Page 2, and accept responsibility for

repayment to ECSU and/or VA if required. I understand the terms and conditions and acknowledge that

the information I have provided here is correct.

Full Time__ Part-time__Guest__ (Must have letter from parent school for authorization)

Signature ____________________________________________________ Date ______________________

Revised 11-Jan-16

Data Form - Va Benefits Application Form

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