Quarterly Veterans Center Benefits Request Form
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Please complete both sides of this form and attach any additional information including a printed copy of your course
schedule on GOLD for the quarter that you are applying to receive benefits. This schedule should be signed and dated by
your academic department or college advisor verifying that all units you are requesting certification for are required and/
or necessary to successfully complete your current degree/major program.
STUDENT INFORMATION:
Quarter: ________________ , 20______
Name:______________________________ SS #:__________________
PERM #:__________________
DOB:________
Local Address:___________________________________________________________________________________________
Street
Apt.#
City
State
Zip
Mailing Address:________________________________________________________________________________________
Street
Apt.#
City
State
Zip
Primary Phone: (
)____________________________
Primary Email: ______________________________________
Other Phone: (
)____________________________
Other Email: _______________________________________
BENEFITS INFORMATION:
Please check the type of veterans educational benefits that you are eligible to receive:
❑ CHAPTER 30: Montgomery G.I. Bill —Active Duty
(include copy of VAF 22-1990 Application for VA Educational Benefits, or 22-1995 and DD-214)
❑ CHAPTER 31: Vocational Rehabilitation (VOC)
(Please include verification of your eligibility, VA Form 28-1905)
❑ CHAPTER 35: Dependents Educational Assistance Program (DEA)
My VA File Number is (Include suffix): ______________ or call (888) 442-4551 to get your VA file number
(Please include a copy of VA form FAF 22-5490 or 22-5495)
❑ CHAPTER 1606: Montgomery G.I. Bill — Selected Reserve
(Please include your VA Form 22-1990, or 22-1995)
❑ CHAPTER 1607: REAP
Reservists who were activated for at least 90 days after September 11, 2001 – go to to
confirm your eligibility and/or call (888) 442-4551. (Please include VA Form 22-1990, or 22-1995)
Please check one of the following
:
This is the first time that I have applied for Veterans benefits.
❑
Attached is my Application for Veterans Chapter Benefits (22-1990 or 22-5490)
❑
I have already submitted my Application for Veterans Chapter Benefits with the VA
❑
I am a continuing Veteran’s Chapter benefits recipient from last quarter, or a previous term.
❑
I am a transfer student and I received Veteran’s Chapter benefits at my former college
❑
Attached is my VA Change of Program or Place of Training form (22-5495 or 22-1995)
❑
I have already submitted my Change of Program or Place of Training form to the VA.
❑
Months of remaining entitlement (if known):___________
Please attach your Certificate of Eligibility Letter from the Veterans Administration.
Continued on back of page
For office use only.
Date
Date
Date
Date
VA Once
_____
D18 Screen
_____
Contact List
_____
Sticker
_____
Advance Pay
_____
D22 Screen
_____
Category
_____
File
_____
Master File
_____
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