Request Form For Va Benefits printable pdf download

Nicholls State University

Request Form for VA Benefits

A new form must be completed and given to the Certifying Official EACH semester you want to receive VA benefits. If not

completed, you will not be certified and you will not receive your VA benefits. By completing and signing this form you

are giving the Certifying Official permission to release your information to the VA, your academic, adviser & Fee Collection.

Name ________________________

Social Security Number _________________ Date of Birth _______________

VA File # (Spouses and Dependents Only) __________________________

Mailing Address_______________________________________________________

Is this a new address? Yes/No

Street

City

State

Zip

E-mail Address _______________________________________ Daytime Phone Number _______________________

Please check one of the following:

____New student requesting VA benefits:

___ paper application ____VONAPP

____Continuing student : ____ already receiving VA benefits

____ never received VA benefits

____Transfer student:

____ already receiving VA benefits

____ never received VA benefits

Please indicate which VA Program you are applying for or receiving:

Chapter 30

Chapter 31

Chapter 33

Chapter 1606

Chapter 1607

Chapter 35

Veteran____

V/R____

Post 9/11____

National Guard____

REAP____

Dependent ____

Reserves ____

Spouse

____

War Orphan ____

Eligible and receiving:

National Guard Tuition Exemption? Yes or No

Tuition Assistance? Yes or No

Financial Aid and/or Scholarships? Yes or No

Please certify the following:

Major: _____________________________________

Hrs______ Spring _______

Is this a change of major? Yes or No

Hrs______ Summer _______

Hrs______ Fall _______

Degree: _____________ (ex: AS, BA, BS, BGS, MS, MBA)

Hrs______ Winter Session ______

Is this a change of degree program? Yes or No

Repeating any class(es): Yes or No If yes, list ________________________

Ever declared Academic Amnesty/Renewal: Yes or No

If yes, at what University?__________________________ List repeating classes?____________________________

Taking any classes not required in your degree curriculum? If yes, please list ________________________________

I agree to promptly inform the Certifying Official of any changes in my status. I understand that I will be

responsible for any debts I incur from the VA and/or NSU due to my changes in academic information. I

understand that the VA does not pay for: more than one degree, minors, course(s) not in my degree

curriculum, dropped course(s), audited course(s), course(s) already successfully completed (according to

degree curriculum) or any course(s) covered under Academic Renewal/Amnesty, and repeated course(s)

for raising GPA. I know that unsatisfactory progress (academic probation and suspensions), dropped

classes, resignations and non attendance will be reported to the VA and may cause an overpayment.

Signature_____________________________________

Date_________________________________

REV02.29.2012

Request Form For Va Benefits

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