State Form 20234 - Application For Remission Of Fees For A Child Of A Disabled Veteran -Application For Free Tuition For Children Of Pow/mia
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1APPLICATION FOR REMISSION OF FEES FOR A CHILD OF A DISABLED VETERAN
APPLICATION FOR FREE TUITION FOR CHILDREN OF POW/MIA
* * VETERAN DATA * *
1. First Name
Middle Name
Last Name
`
2. Soc. Sec.#
-
-
VA File #
Service #
3. Address
City
State
Zip
4. Branch of service
Dates of service: From: m/d/y
To: m/d/y
Date of birth (m/d/y)
5. Telephone # (
)
Is the Veteran deceased ? ( ) Yes ( ) No If yes, Date of death(m/d/y)
** STUDENT DATA * *
6. First Name
Middle Name
Last Name
7. Soc. Sec.#
-
-
Date of Birth
Relationship to Veteran
8. Code number of State school student will attend
Start Date (m/y)
(see instructions for a list of eligible schools)*
9. Check the degree this application will be used toward: (a) Undergraduate
(b) Graduate
10. List whether you will attend the school listed in question 8, full or part time. (a) Full Time
(b) Part Time
11. Student’s Address
City
State
Zip
12. Has the student been a resident of Indiana for one year prior to filing this application ( ) Yes
( ) No
13. Check one of the following ( ) Child of a Disabled Veteran
( ) Child of POW/MIA
( )Child of Purple Heart Recipient (Documentation required for Purple Heart)
14. Have you or a family member previously receive Remission of Fees under this program? ( ) Yes ( ) No
15. Have you or a family member previously receive free tuition as a child of a POW/MIA? ( ) Yes ( ) No.
16. I certify that the above statements are true and correct.
Student Signature
Date of Application (m/d/y)
Intentional falsification of data can result in loss of benefits
**********
DO NOT WRITE BELOW THIS LINE **********
( ) Veteran Data Entered
( ) Student Data Entered
APPROVED
NOT APPROVED
1.
( ) verify service in the armed forces during wartime.
1. ( ) cannot verify service in armed forces during wartime
2.
( ) verify a discharge under other than dishonorable conditions
2. ( ) cannot verify a discharge under other than dishonorable conditions
3.
( ) verify award of the Purple Heart Medal/ wounds received
3. ( ) cannot verify award of the Purple Heart Medal/wounds received
4.
( ) verify a service connected disability of record
4. ( ) cannot verify a service-connected disability of record
5.
( ) verify veteran classified as POW/MIA, after January 1, 1960
5. ( ) cannot verify classification of POW/MIA after January 1, 1960
6.
( ) verify veterans service connected death.
6. ( ) verification of eligibility cannot be made with the data provided
NOTE: This certification does not verify relationship of the student to Veteran
IDAV VERIFICATION SIGNATURE
Date
Not Valid Without Embossed IDVA Seal
* This application is null and void if the school on line #8 is not a state supported school (see reverse under entitlement)
This Form Can Not and Will Not Be Returned By Facsimile Equipment
State Form 20234 (R5 / 4-00)
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