Data Form - Va Benefits Application Form Page 2
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4Important Information
The VA will hold you responsible for any education benefit overpayment from reduction or termination of
your enrollment even if the payment was submitted to the school on your behalf.
Chapter 33 Recipients – Though you may be approved for 100% tuition benefits under the Post 9/11 Bill
(Chapter 33), VA only pays the full undergraduate in-state tuition rate established for the Fall semester.
Subsequent tuition increases during the academic year may not be fully paid by VA. Check your account
balance on e-web and contact the Bursar if you have any questions.
Terms and Conditions
1. If you wish to use your VA benefits you must complete this form each semester after you have
registered for your classes (bring class schedule to the financial aid office with this form completed).
2. I understand that I must be enrolled in a program of study leading to a standard college degree by the
end of the second term of enrollment in order to received VA benefits.
3. I understand that I can only receive benefits for courses required for my degree and that I must make
satisfactory progress towards graduation. I understand that withdrawal from courses and subsequent
grades of “W” may reduce VA payment eligibility. I understand that the VA will not pay for courses
that I audit, take without credit, and or do not attend, and that the VA will hold me responsible for any
education benefit overpayment.
4. In accordance with the Privacy Act of 1974 (Public Law 93-579). I authorize the Department of Veterans
Affairs to review and discuss my academic records with an official representative of Eastern
Connecticut State University.
5. Chapter 31 only – I understand that my Vocational Rehab counselor must submit a VA form – 1905
before my certification will be submitted to the VA.
Revised 11-Jan-16
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