Student Worksheet For Va Education Benefits
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2STUDENT WORKSHEET FOR VA EDUCATION BENEFITS
(this form is to be completed by the student once, before the first term of enrollment at PSC)
1. NAME: _______________________________________________
VA CLAIM # (SSAN OR C#): ________________________________
(If you are applying for dependents’ education assistance, please provide the veteran’s VA file number)
MAILING ADDRESS: ___________________________________________________________
PHONE: ___________________ E-MAIL __________________________________________
2. VA benefit education program you are applying for (Please check one):
___ Montgomery GI Bill-Active Duty (Chapter 30 – Active duty after 7-1-85)
___ Montgomery GI Bill-Selected Reserves (Chapter 1606 – Reserve and National Guard)
___ Reserve Educational Assistance Program (REAP – Chapter 1607)
___ Dependents and Survivors Educational Assistance (Chapter 35)
___ Post-9/11 GI Bill (Chapter 33 – Effective August 1, 2009)
___ Veterans Educational Assistance Program (VEAP – Chapter 32)
___ Vocational Rehabilitation (Chapter 31)
3. Have you previously used VA education benefits? YES/NO If yes, complete Items 4 and 5 below.
4. Please list the schools that you have attended and received VA education benefits.
____________________________________ ____________________ __________________
School
Program of Study
Date(s) Attended
____________________________________ ____________________ __________________
School
Program of Study
Date(s) Attended
5.
Please list all post-secondary schools, colleges, and universities you have attended without VA benefits
(use reverse side of this sheet if necessary).
____________________________________ _____________________ _________________
School
Program of Study
Date(s) Attended
____________________________________ _____________________ __________________
School
Program of Study
Date(s) Attended
6. Are you currently on active duty in the Armed Forces? YES/NO
If so, are you receiving Tuition
Assistance from the Department of Defense? YES/NO
7. Have you received VA education benefits before? If so, have you completed VA Form 22-1995 or VA Form
22-5495 if you are a dependent? Both forms are available at the VA Education website –
(see link “How to Apply”) If you have never applied for VA education benefits before,
you will need to complete VA Form 22-1990 or VA Form 22-5490 if you are claiming benefits as a
dependent. All of these applications can be filed electronically from the GIBILL web site.
8. If you have questions regarding your VA education benefit, please contact the VA directly. You may call
the toll-free Education Phone Number 1-888-442-4551 or use the “Ask A Question” feature on the GIBILL
web site.
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