2011-12 APPLICATION FOR REMISSION OF FEES FOR A CHILD OF A DISABLED
INDIANA VETERAN OR A POW/MIA
State Form 20234 (R23 / 1-11)
*This agency is requesting disclosure of your Social Security Number (SSN) in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be
processed without it.
Important: Application must be completed in ink – not pencil. Applicants must also annually file a clean, edit-free Free Application for Federal
Student Aid (FAFSA), preferably by the State Student Assistance Commission of Indiana’s (SSACI) March 10 (date received) filing deadline, but no
later than thirty (30) days prior to the end of the semester. The FAFSA can be filed online at To help ensure your school has
time to bill SSACI for your remission of fees by each semester’s deadline, it is recommended that approved applications be submitted to the financial
aid office at your school no later than thirty (30) days prior to the end of the semester.
1. First Name _______________________________ Middle Name _______________________ Last Name ______________________________
2. SSN * ____________________ VA File number (if different from SSN) ______________________ Service number ______________________
3. Is the Veteran deceased?
If yes, Date of death (mm/dd/yy) __________________
4. Current Address (or, if deceased, last known address) _____________________________________________ City _______________________
State ____________________ ZIP code ____________
5. Branch of service ______ Dates of active duty service: From (
6. Telephone number (______) ______________
7. Has/had the veteran been a resident of Indiana for 36 consecutive months?
If Yes, Dates (mm/yy): _____________________
***STUDENT DATA ***
8. First Name _______________________________ Middle Name _______________________ Last Name ______________________________
9. SSN * ___________________ Date of birth (mm/dd/yy) _________________Relationship to Veteran _________________________________
Check one: Your relationship to the veteran is:
legally adopted child
(Students MUST attach copies of their birth certificate or court adoption papers. If you are neither, you are not eligible for the benefit.)
10. Have you received Child of Disabled Veteran tuition and fee remissions for any prior academic year?
No If so, when? _____
List academic years and college(s) attended ________________________________________________________________________________
11. Name of school attending:_______________________________________________________________________________________________
12. Corresponding school code number of the public college student will attend (college codes are listed in Section 4): __________
13. Semester start date you are applying for (mm/yy):__________
14. Check the degree this application will be used toward:
15. List whether you will attend the college listed in question 11 full or part-time:
16. Student’s Address _____________________________________________ City ____________________ State ______ ZIP code __________
Telephone number (_____) ___________________ Email: ___________________________________________________________________
17. Check which one you are:
Child of a Disabled Veteran
Child of POW/MIA (after January 1, 1960)
Child of Purple Heart Recipient (The veteran’s DD214 showing the Purple Heart MUST be attached to
18. Certify by signing and dating that the above statements are true and correct and that you have read this form’s Filing Instructions.
Student Signature ____________________________________________________ Date of Application (
By signing this application you agree that the information you have provided is true and, if asked, to provide documentation that will verify the
accuracy of the information you have provided on this application and that you have read and understand the application’s Program Information
and Filing Instructions. WARNING: If you give false or misleading information, you may be fined, prosecuted or both.
FOR IDVA USE ONLY*
*FOR IDVA USE ONLY*
Served in the armed forces during wartime
Cannot verify service in armed forces during wartime
Discharged under other than dishonorable
Cannot verify a discharge under other than dishonorable
Awarded of the Purple Heart Medal / wounds received
Cannot verify award of the Purple Heart received
Has service-connected disability of ________ % disability
Cannot verify a service-connected disability of record
Classified as POW/MIA, after January 1, 1960
Cannot verify classification of POW/MIA after January 1, 1960
Service connected death
Verification of eligibility cannot be made – insufficient data
Birth Certificate or court adoption papers attached/on file
Birth Certificate or court adoption papers not attached
First time applicant
Veterans’ residency information not verified
Invalid School Code/Non Approved Indiana School
IDVA VERIFICATION SIGNATURE ______________________________________ Date (mm/dd/yy) ______________Not Valid Without Embossed IDVA Seal.
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