Fill - Free fillable Admissions Veterans Certification Request Change (Blue Ridge Community College) PDF form

E-mail: Veterans@brcc.edu

Phone: 540-453-2346

Fax: 540-453-2437

Veterans and Dependents Certification Request/Change

Name: _______________________________________________________ EMPLID#__________________

Phone: _____________________Address: _________________________________________________

New student (SS# required):____________________________________

Returning Student

Guest Student (List primary School):_____________________________

*Guest Students must submit a Primary School Letter from their home institution

Transferring from another Institution and used my VA benefits

Name of institution where benefits were most recently used: ________________________NOTE: If

transferring benefit from one school to another you must submit a FORM 22-1995(veteran) FORM 22-5495(dependent). Forms can be

found at VA.gov or obtained by the certifying official.

Please print class schedule as it appears today for the following semester:

Fall Spring Summer Year 20

Please Check One of the Following:

This is the first time I am requesting certification for this semester

This is a change (dropped or added classes) from the original certification for this semester

My benefit chapter is:

 30 (Montgomery GI Bill)  33 (Post 9/11)  1606 (Selective Reserve)

 35 (Dependent) Veteran’s SSN#______________________________ Relationship to you___________________

 Vocational Rehabilitation: Case Manager’s name: ______________________________

 VMSDEP (Dependent State benefit) Do you receive CHAMPVA? Yes No

 3rd Party Pay- Certify for Chapter 33 BAH only (ex: Hershey or TA is paying for tuition & fees but want to receive

my housing)

 Pending (applied online) *classes cannot be held and students cannot be certified for benefits until the student applies at

benefits.va.gov and Blue Ridge Community College receives a copy of the Certificate of Eligibility Letter.

Program of Study: ____________________________________________

Do all courses apply toward your degree program: Yes No

If no, please list: _______________________________________________________________________

Are you registered for a Repeat Course(s) (only if taken multiple times at BRCC): Yes No

If yes, please list: _______________________________________________________________________

E-mail: Veterans@brcc.edu

Phone: 540-453-2346

Fax: 540-453-2437

Blue Ridge Community College-Veterans Services Office

Student Responsibilities

By signing below, student understands and agrees to the following:

 Each semester I must request to be certified and report any changes in my schedule by submitting a Veterans

and Dependents Certification Request/Change Form

 All classes I take must apply towards my program of study at BRCC. If I drop a class or take a class that does

not apply, I will be responsible for overpayment that is due to the VA or BRCC. If there is a special

circumstance (i.e. required for transfer, specific program, etc.) contact Michelle Eye at Veterans@brcc.edu

 I must notify BRCC Veterans Services if I decide to change my program of study

 I will monitor my VCCS email account for all college communications

 I understand that I may also apply for Federal Financial Aid at fafsa.gov which may be used along with my

VA Education Benefits

 I understand that I can seek credit through prior learning by requesting my military transcripts for evaluation

and I should speak with the Veterans Advisor about this process

 I must submit a DD214(if applicable) and updated copy of my Certificate of Eligibility to Veterans Services

in order to be certified

 I understand that dropping/adding or not attending courses after the original certification may result in debt

owed to the VA and/or delay in payment

 I am responsible for informing the School Certifying Official or Veterans Advisor when changes are made to

schedule and/or program within 15 days of change

 I understand that if I do not inform BRCC of my class changes that my certification will be adjusted

accordingly

 Book stipends for Post 9/11 CH 33 benefits are only provided for fall and spring semesters and do not always

arrive before classes begin—Student is responsible for coursework regardless of payment issues.

 Developmental Courses (ENF and ESL courses) taken online will not be covered by your VA benefits

 I understand that if my schedule is entirely online that my monthly stipend may be significantly reduced for

Post 9/11 benefits

 I understand that I am responsible for any charges not covered by my VA benefits

 I understand that if I am taking repeat courses that a higher grade must be received in the second attempt of

the course or I will owe ALL expenses associated with the repeated credit(s) to the VA

 Most “Hybrid” classes will be certified as “distance” or “online” which can impact BAH payments. Please

see the School Certifying Official if you have questions about if a class is technically “online” or “in person.”

By signing below, you are acknowledging that you have read the above rights and responsibilities and

understand them.

Signature: _____________________________________________Date: _______________________

For Office Use Only:

COE: # of Credits:

DND: Certified:

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