--Office use only--
Received by:
Prior IHL Check:
GPA:
Date Processed:
Date Received:
22-1995/5495:
Hrs. SIS:
Certified by:
Verify Degree (VA/IECP/RfB):
Tuition Deferment:
Prev. Balance:
Vet Benefits Page:
Contact Info Verified:
Class Hold:
2P Notes:
Cert Notes:
I’m requesting Veterans Benefits under the following Chapter:
□ CH 33 Post-9/11 at _______% □ CH 33 Post-9/11 Transfer of Entitlement □ Fry Scholarship
□ CH 30 Montgomery GI Bill □ CH 31 Veterans Vocational Rehabilitation □ CH 35 Dependent & Survivor’s Assistance
Applicant Information Student ID # ____________________________
Social Security # _________-_______-_____________ VA File # (Ch. 35 only) _________________________________
First Name ________________________ M.I. __________ Last Name _________________________________________
Phone Number__________________ DOB___________ Branch of Service(Vet Only)_____________ Currently active duty? □ Yes □ No
Home Address _________________________________________________________Discharge Month and Year_____________
City ____________________ State ______ Zip ___________ Email address _____________________________________
□ CH 1606 Selected Reserve/Guard □ CH 1607 Reserve Educational Assistance (REAP)
Which Associate or Certificate Degree Program are you pursuing?
□ AA-Associate in Arts □ AS-Associate in Science □ ABUS-Associate in Business (General Requirements)
AAEE-Elementary Edu. AAFA-Dance AAFA-Art AAFA-Theatre □ ABUS-Associate in Business (Special Requirements)
AGS-Associate in General Studies
□ AAS-Associate in Applied Sciences (please list specific program) ____________________________________________
□ CCL-Certificate of Completion (please list specific program) ________________________________________________
MAPP-Maricopa ASU Pathways Program (please list specific program)______________________________________
Other Program of Study______________________________________
Do you currently have a degree? □ Yes □ No List the degree you have ______________________________________
Class ( Ex: ENG 101)
Credit Hours
Hybrid?
Course Start Date
Course End Date
Tuition & Fees (office use)
Semester Information
Veterans Services Request for Benefits Form
Continued on back…
Requesting Certification for: □ Spring □ Summer □ Fall Year: 20______
Is this your first semester using benefits at this school? □ Yes □ No
Will you be attending more than one college this semester? □ Yes □ No
If yes, where else? _________________________________
Are you requesting a deferment of your tuition & fees for this semester? □ Yes □ No
Will you be requesting a loan from the college to pay for books (this is NOT the Ch. 33 book stipend)? □ Yes □ No
Will you be requesting Advance Pay from VA (not available for Ch. 33)? □ Yes □ No
Will you also be receiving any of the following this semester? □ Yes □ No
(Please select all that apply) □ Scholarship □ Military Tuition Assistance □ Employer Tuition Assistance □ Tuition Waiver
8 characters long, Starts with 3.
Revised: 10/18/2016
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Yes
No
Yes
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No
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Acknowledgements
Degree Program: I understand that VA educational benefits will only pay for classes that are required for my selected degree
program at my current college. If I take courses outside of my program, it is my responsibility to make payment. ________ (Initial)
Changes: I will notify the Veterans Services office of any changes in class schedule, start dates, degree, or address. Failure to notify
the Veterans Services office may result in a debt to the VA. ________ (Initial)
Non-Standard Classes: I understand that short-term classes and Open Entry/Open Exit classes will affect how my benefits are
processed, as well as my full-time level. ________ (Initial)
Attendance: I understand that if I do not attend class, I am not entitled to receive benefits. I understand that my benefits are based
on class “seat time.” All withdrawals will be reported to VA with my last date of attendance. ________ (Initial)
Academic Probation: The Maricopa Community colleges have minimum GPA requirements (see college catalog). Failure to maintain
the required GPA will result in academic probation. You are still eligible for educational benefits while on academic probation;
however remaining on probation for two consecutive semesters may result in the Department of Veterans Affairs suspending or
terminating your benefits. ________ (Initial)
Courses and Grades: Acceptable grades are A, B, C, D, F, and P (for required courses only). Courses not successfully completed may
be repeated and covered by VA Education Benefits. Courses not successfully completed may be repeated and covered by VA
Education Benefits. Withdrawing (W and Y) from classes during a semester may create a debt to VA. Remedial courses taken
ONLINE or audited courses are not authorized for VA benefits. ________ (Initial)
Prior Credit: I understand that VA rules require me to transfer all prior college and military credit. I agree to order official college
and military transcripts and understand I may not be certified without all prior credit being evaluated by the college. I give the
Maricopa Community Colleges permission to request my military transcript on my behalf. ________ (Initial)
Tuition Deferments: I understand it’s my responsibility to make sure my tuition and fees are paid by the established deferment
deadline dates. Failure to pay my tuition and fees will result in my account being turned over to a collection agency and reported to
the credit bureaus. I’m responsible to pay back this deferment, even if I do not attend classes or fail to withdraw myself by the
refund deadline date. Failure to pay will create a debt, resulting in inability to register for, or cancellation of enrollment in, future
classes. Requesting benefits is not a guarantee of VA payment, and I am responsible for any amount not paid by VA.________ (Initial)
Other Financial Assistance: The Post-9/11 GI Bill will not pay tuition if you are receiving a tuition waiver, if you are using military
Tuition Assistance, if your employer is paying your tuition, or you have an outside scholarship/grant funding specifically designated
for the sole purpose of paying for tuition and fees (exception Title IV funding). ________ (Initial)
Tuition Assistance(T/A): I understand that I cannot use CH1606 or CH1607 benefits and military tuition assistance at the same time
for the same course. I understand that T/A may affect my CH30 or CH33 benefits. ________ (Initial)
_______________________________________________________________ ___________________________________
Student signature Date (MM/DD/YYYY)
Have you used Veteran Education Benefits before? □ Yes □ No
Which is your Parent School?
Chandler-Gilbert CC Estrella Mountain CC Gateway CC Glendale CC
Paradise Valley CC Mesa CC
Phoenix College South Mountain CC
Scottsdale CC Rio Salado Southwest Skill Center
Other ____________________________________
List all institutions you have previously attended.
1)_______________________________________________________________ Transcripts: Requested □ Received □
2)_______________________________________________________________ Transcripts: Requested □ Received □
3)_______________________________________________________________ Transcripts: Requested □ Received □
No
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