3/2020
Veterans/Dependents – VA Educational Benefits – Intake Form
NAME: STUDENT ID #:
ADDRESS: VA File # or SSN#:
CONTACT PHONE #:
EMAIL ADDRESS: Semester/Year:
□ Ch 30 Montgomery GI Bill □ Ch 31 Vocational Rehabilitation □ Ch 33 Post 9/11 GI Bill
□ Ch 1606 Selected Reserve □ Ch 35 Dependent/Survivors □ Ch 33-TOE (transfer of entitlement)
Current Objective – Please indicate your Major listed on your VA educational plan. It must be a degree or
certificate program offered through FLC or a CSU/UC transfer plan. Please select one below:
□ Certificate Major:
□ AA or AS Degree Major:
□ Transfer program Major: Transfer Institution:
Official Transcripts – Official transcripts from all previous colleges and universities attended MUST be on file
prior to making appointment with counselor for VA educational plan (this includes SMART and AARTS
transcripts). List ALL colleges attended:
□ YES, I attended and have transcripts from other colleges outside of Los Rios, as listed below:
College Attended Dates Attended Received in Office (Staff Use)
□ NO, I did not attend and do not have transcripts from other colleges outside of Los Rios.
I understand that my VA educational benefits may be affected if any information provide to FLC is inaccurate
or incomplete.
Student’s Signature Date
OFFICE USE ONLY:
□ VA Application (completed on va.gov website)
□ FLC VA Statement of Student Understanding form
□ FLC VA Request for Certification form (must be completed EVERY semester)
□ VA Educational Plan (schedule appointment with FLC counselor)
□ DD-214 (member 4 copy)
□ Certificate of Eligibility letter
□ Chapter 35 veteran information:
Veteran’s SSN Dependent #
□ DND posted for Chapter 33, 33-TOE and 31 7/2016
