Revised June 29, 2016
Certification Request for VA Educational Benefits
Student Information
Name (First, Middle, Last)
VA File Number/SSN
Student ID
Mailing Address
Primary Phone
Secondary phone
E-mail address
Have you used your VA educational benefits
before? Yes No
Within the last year?
Yes No
If yes, where?
If “NO
Chapter 30 (MGIB) Chapter 31 (Vocational Rehab) Chapter 33 (Post 9/11) VRAP
Chapter 35 (Dependents) Chapter 1606 (Reservist) Chapter 1607 (REAP)
Program of Study
Associate Degree Diploma
Certificate Career Studies Certificate Non-matriculated/Attending another college**
Program of Study:
Is this a change of Program of Study
since you last received VA benefits?*
Yes No
**If attending another college, that school’s certifying
official must provide a parent school letter listing
approved courses each semester.
Prior Training
Have you previously attended any other colleges or universities? Yes No
If “YES”, list the colleges you have previously attended: ______________________________________________________________________________
Please provide an official copy of your transcripts to the VA Certifying Official. Students are ineligible for VA Benefits if credits from prior training are not
reported within two semesters.
Upcoming Semester List of Classes
Fall Spring Summer Year ___________________
Course Name
# of Credits
Office Use
College Composition (example)
Tuition Payment
Cash, Check, Credit Anticipated Financial Aid Vocational Rehab
VMSDEP Benefits Post 9/11 GI BILL Tuition Assistance
Statement of Understanding
1. I must complete this form each semester that I intend to receive VA educational benefits. Failure to do so will delay payment.
2. I must immediately report all changes in enrollment to the Certifying Official. Failure to do so may result in an outstanding debt to the VA.
3. I understand that VA educational benefits may be discontinued if I fail to maintain satisfactory attendance and progress.
4. I cannot receive benefits for a class taken now for which I have previously received a passing grade, whether here or at another institution.
5. I must have my DD-214/NOBE/transcripts from any previous colleges forwarded to the Certifying Official for evaluation of transfer credit.
6. I will only receive VA educational benefits for courses specifically required in my curriculum, except during the semester of graduation.
7. I understand all written correspondence between me and my WCC VA Certifying Official will be via my official student e-mail account.
8. I understand that I am responsible for payment for my books/supplies and my tuition.