Sample Request For Top-Up: Army Tuition Assistance Program
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1
2REQUEST FOR TOP-UP: Army Tuition Assistance Program
P
A
S
RIVACY
CT
TATEMENT
:
38 USC 3104, Payment of Basic Educational Assistance; 10 USC 3013, Secretary of the Army; 10 USC 4302, Enlisted Schools; 10 USC 2007, Tuition Assistance;
A
UTHORITY
AR 621-5, Army Continuing Education System (ACES), and E.O. 9397 (SSN).
:
To record information required by the Department of Veterans Affairs in order to process "Top-Up" claims from GoArmyEd Army Tuition Assistance participants.
P
P
RINCIPAL
URPOSES
:
None. The “Blanket Routine Uses” set forth at the beginning of the Army’s compilation of systems of records notice apply to the system.
R
U
OUTINE
SES
:
Voluntary. However, failure to furnish personnel identification information may prevent the Department of Veterans Affairs from processing the "Top-Up" claim.
D
ISCLOSURE
1. APPLICANT INFORMATION:
Name: _______________________________ SSN: _______________ Address: ___________________________________________
Email: _______________________________ Telephone number: _____________________ Date Entered on Active Duty (BASD): _________________
2. SCHOOL INFORMATION:
Name of Home School: _________________________________________ Name of School Offering Course: __________________________________
Address of Home School: ________________________________________ Address of School Offering Course: ____________________________
3. COURSE INFORMATION:
Name of Course: _______________________________________ Course Number: ________________ # Semester Hours (or equiv.): ________
Date Course Began: ______________________ Date Course Was Completed: ______________________ Final Grade: _____________
(Final Grade is not required for submission to VA)
4. COURSE COST & TUITION ASSISTANCE INFORMATION:
Total Cost of the Course: _______________ Total Amount of Tuition Assistance Paid by Army for the course: _____________________
Total Amount Paid by Soldier for the Course: _______________
5. COURSE ENROLLMENT/COMPLETION VERIFICATION OFFICIAL:*
Title: _____________________________ Name: ________________________________ Signature: _______________________________
Telephone number: ____________________
6. SOLDIER’S SIGNATURE (By signing below, I affirm that the information on this application is true and complete to the best of my knowledge. I
am a Montgomery GI Bill [MGIB] participant and have read the Army Tuition Assistance Information Sheet that accompanies this form. I
understand how the use of Top-Up will reduce my remaining entitlement under the MGIB.)
Printed Name: __________________________________
Signature: ________________________________ Date: ___________________________
1 Apr 2006
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