Name
_________________________________________ Social
Security Number _______________________
Address
_______________________________________ E-Mail
Address ______________________________
_______________________________________ Telephone: ( ) ____________________________
Please complete all
questions so that processing will not be delayed. Please complete one form per semester.
1. Please indicate the Semester you wish to be
certified for: _______ Fall
_______ Spring
_______ Summer
2. Which VA
Education Benefit Program are you requesting to be certified under this
semester?
________ (Chapter 30)
________ (Chapter 31)
Vocational Rehabilitation
________ (Chapter 1606) Montgomery (Selected Reserve/National Guard)
G. I. Bill
________ (Chapter 1607) Reserve Education Assistance Program (REAP)
________ (Chapter 35)
Survivors’ and Dependents
Educational Assistance (DEA) V.A. Claim Number ___________
3. Have you completed the application for VA
Education benefits through VONAPP or on paper?
_____Yes _____No
4. Have you ever been certified under this VA
Education Benefit Program before? _________Yes
_________ No
If yes, where were you last
certified? _____ Ivy Tech
–
If another school, what was the name and
address of the other school? ______________________________________
5. Please list all other institutions that you have
attended ____________________________________________________
6. What specific Degree Program are you enrolled
under? __________________________________________________
Have
you changed your degree program since the last time you were certified for
benefits? ______Yes _______No
7. How many hours are you enrolled in for the
current semester? _______________
8. What is your expected date of
graduation? ___________________ (Month/Year)
9. Do you have a Kicker contract? ______Yes _____ No If yes, how much per month? $______________
Please Note: Classes that do not meet for the full length
of the semester are only included during the period they meet. Department of Veteran Affairs (DVA) will
exclude them during the rest of the semester when deciding how much you will be
paid. You are paid for attendance in classes.
Any changes in course
enrollment after certification has been submitted to DVA may result in the
retroactive loss of benefits. Loss of
benefits could revert back to the first day of class. Courses added during the add/drop period are
considered by the DVA to begin on the day the course was added, not the first
day of the session.
I AM AWARE THAT CHANGES IN MY
ENROLLMENT MAY ALTER THE PAYMENT THE DVA WILL AWARD ME. I understand that I will be responsible for
any overpayment that I might receive from the DVA. I also understand that I must notify the VA
Certifying Official at
I AM ALSO AWARE THAT I MUST COMPLETE
THIS FORM EACH SEMESTER AFTER REGISTERING FOR ALL CLASSES. I hereby certify that all statements are true
and complete to the best of my knowledge and belief.
______________________________________________ _______________________________________
SIGNATURE DATE
Office
of Financial Aid