Fillable Illinois Veteran Grant Program Application

1755 Lake Cook Road

Illinois

Deerfield, IL 60015-5209

Student

800.899.ISAC (4722)

Assistance

E-mail:

Commission

ILLINOIS VETERAN GRANT (IVG) PROGRAM APPLICATION

WARNING: Any person who knowingly makes a false statement or misrepresentation on this application shall be subject to prosecution to the fullest extent of the law.

Data may be verified with appropriate authorities of federal and state agencies.

Please print legibly in ink or type. Before completing this application, read both pages and gather all required documentation. Allow at least four weeks for

processing of this application.

Social Security Number

Last Name

First Name

Prior Last Name, if applicable

E-mail Address

Permanent Address

Area Code and Telephone Number

(

)

City

State

ZIP Code

County

Are you residing in Illinois?

If No, State in which you are currently residing:

Also if “No”, you must provide documentation specified under Eligibility Requirements on page 2, item 3.

Yes

Applicant’s Federal Active Duty Service Information

Refer to your Department of Defense (DOD) Certificate of Release or Discharge from Active Duty (DD214 Member 4 or equivalent copy) to complete this section.

Dates of initial federal active duty service

From:

To:

month/day/year

If you reenlisted, extended, or were called to federal active duty from a Reserve component of the Armed Forces of the United States or Illinois National

Guard, list the most recent period of additional federal active duty service

From:

To:

month/day/year

Are you currently serving on federal active duty as a member of the Armed Forces of the United States? (see page 2, item 1 under Eligibility Requirements for

definition) (see note under Application Procedures on Page 2)

Yes

Were you called to federal active duty from a Reserve Component of the Armed Forces of the United States or the Illinois National Guard?

Yes

If you answered “Yes” to 2 and “Yes” to 3 above you must submit a letter from your Commanding Officer*. Also, if you had a break in service you must submit a

DD214 Member 4 or equivalent Department of Defense (DOD) documentation for each period of federal active duty service.

If you answered “Yes” to 2 and “No” to 3 above you must submit a letter from your Commanding Officer * and a copy of the Enlistment/Re-enlistment document

confirming enlistment and/or extension agreements for all periods of enlistment/re-enlistment/extension. (Commissioned officers must submit their “Officer

Appointment Acceptance and Oath of Office” document). Also, if you had a break in service you must submit a DD214 Member 4 or equivalent Department of

Defense (DOD) documentation for each period of federal active duty service.

If you answered “No” to 2 and “Yes” or “No” to 3 above you must submit a DD214 Member 4 or equivalent DOD documentation for each period of federal active

duty service.

*The letter from the Commanding Officer (on departmental letterhead) must indicate you are a member of the Armed Forces of the United States, your character of

service, your home of record at the time of original enlistment, your length of service and the expiration date of your current enlistment.

Please note: A DD214 Member 1 or Worksheet is not equivalent to the DD214 Member 4. If the DD214 Member 4 lists prior federal active duty service, a

DD214 Member 4 or equivalent must be submitted for each period of federal active duty service.

Have you previously applied for or used the Illinois Veteran Grant?

Yes

Were you an Illinois resident at the time of both entering and leaving federal active duty service?

Yes

If “No”, or if your DD214 Member 4 or equivalent DOD documentation does not verify residency by indicating home of record as “Illinois,” you must provide

documentation specified under Eligibility Requirements on page 2, item 3.

Answer the following only if you served less than one year of federal active duty service:

Were you separated for medical reasons directly connected with your service?

Yes

(If “Yes” to question 6a, you must attach an Armed Forces of the United States Medical Review Board Statement or equivalent DOD documentation).

Were you separated prior to August 11, 1967?

Yes

Did you serve in a foreign country in a time of hostilities in that country?

Yes

(If “Yes” to question 6c, this must be indicated on DD214 Member 4 or equivalent DOD documentation.)

Sign and date this certification section:

I certify, under the penalties of perjury as provided by law, that all information on this application, and the required documentation submitted with the application, is true

and correct. I have read both pages of this application and have attached all required documentation before signing it. I certify that I do not owe a refund on any

federal or state grant. I understand that I must establish satisfactory repayment arrangements if I am in default on any federal student loan. I certify that I am in

compliance with federal Selective Service registration requirements. Further, I give my consent to the federal and state departments of Veterans’ Affairs, the Armed

Forces of the United States, National Guard, Reserves, federal Selective Service, and the institution I attend to release information to the ISAC concerning my eligibility

for the Illinois Veteran Grant (IVG) Program. I certify that this is a true and original application form provided by ISAC.

Applicant’s Signature

Date

FOR ISAC USE ONLY

New IVG Number

Old IVG Number

ISAC #F103 07/05

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Printed by authority of the State of Illinois