Form Dvs-40 - College Fee Waiver Program For Veterans Dependents - California - 2017
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2CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS
FOR VETERANS DEPENDENTS
COLLEGE FEE WAIVER PROGRAM
PLEASE READ THE INSTRUCTIONS AND INFORMATION
CONTAINED ON THE REVERSE SIDE
I. STUDENT INFORMATION
Last Name:___________________________First:____________________ MI:_____ Social Security Number:________-_______-____________
Date of Birth: ____/____/___ Phone #: (
)_____ - ________ Marital Status: Married Single Student E-mail: ____________________
Street Address: ______________________________________________City: _________________________State: ________ Zip: _____________
STUDENT’S relationship to veteran in Section III below: ______________________________________________
HAVE YOU APPLIED FOR THIS BENEFIT BEFORE? YES NO
YES NO
ARE YOU receiving, OR ARE YOU CURRENTLY eligible to receive VA EDUCATIONAL BENEFITS UNDER CHAPTER 35?
ADJUSTED GROSS INCOME (AGI) of student from last year (January 1st through December 31st): $______________________
*NOTE: Refer to “HOW TO APPLY” on the reverse for required statements, if you entered zero on AGI and Annual Value of Support.
ANNUAL VALUE OF SUPPORT
received from a parent: $ ____________________________
*Note: examples of support include, but are not limited to: college housing, transportation, books, school supplies, medical care etc…
Note: Under plan B, the total amount of the child’s income and value of support, as listed above, cannot exceed the “national poverty level” as determined by the U.S.
Census Bureau and published by the California Department of Veterans Affairs.
II. SCHOOL INFORMATION
CALIFORNIA COLLEGE or UNIVERSITY you are attending or plan to attend: ________________________________________
ACADEMIC YEAR for which you are requesting waiver of tuition/fees: ________________________________________________
III. VETERAN INFORMATION
Name served under: Last Name: ___________________________________ First: _____________________________ MI: ________
Street Address: ___________________________________________City: ________________________State: _______Zip: _________
Telephone Number: (___)_________-__________ Branch of Service: ______________ VETERAN’S E-mail: ___________________
Date of Birth: ________/_____/_______
Date of Death (if applicable):_____/_____/_____ VA Claim #:______-______-_______
Dates of Active Duty service FROM: _______________ UNTIL: ______________
Service#/SSN#:__________________________
If the veteran is alive, current percentage of service-connected disability adjudicated by the military or USDVA: _________%
If the veteran is deceased, was the death "service-connected," or did the veteran have a service-connected disability at the time of death? YES NO
I hereby certify under penalty of perjury that the information contained in this application and supporting documents is given for the purpose of obtaining educational
benefits and is true, correct and complete. I authorize the California Department of Veterans Affairs (CalVet) employees, officers, and designees to verify these
documents. I hereby authorize the U.S. Department of Veterans Affairs, Department of Defense, Employment Development Department and the Franchise Tax Board,
to release information regarding my service-connected disability rating and/or income to CalVet with the understanding that the department will keep such information
confidential. Further, I understand that educational benefits may be denied if any information is found to be incomplete or inaccurate.
Signature of VETERAN (or Parent if Veteran not available): _________________________________________
Date: ________/________/_______
(If Parent or Veteran is unable to sign, a statement as to why the veteran is unavailable must be attached)
Signature of STUDENT: ___________________________________________________________________
Date: ________/________/_______
DVS-40 (1/17)
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