College of the Siskiyous
AB 13 (VACA) Affidavits for Eligible
V e t e r a n s
California Nonresident Tuition Exemption Request
STUDENT: Complete and submit form and provide proof of eligibility via 'Certificate of Eligibility' or 'DD214'
Student ID# (Cannot be processed without ID):
Print Full Name (as it appears on your college student application/records):
Would you like to be contacted of your status
Yes (you will be contacted through
your ins.siskiyous email account)
Print Full Mailing Address (Number, Street, City, State, Zip Code):
Semester you are applying:
I declare the following, under penalty of perjury:
I am a
dependent (spouse or child) who qualifies for an exemption from
nonresident fees under Section 702 of VACA.
I understand that I must be physically present in California in order to qualify for this exemption.
I understand that I must enroll at College of the Siskiyous within 3 years of my discharge date (or the
discharge date of the member in cases of dependents) in order to qualify for this exemption.
I understand that I must have served at least 90 days in active duty status (or in the case of dependents,
the member must have served at least 90 days in active duty status).
I understand that I must provide proof (attach documentation) of eligibility via (check one below):
Certificate of Eligibility of student showing eligibility for Montgomery GI Bill Active Duty or
Post-911 GI Bill education benefit programs (Chapters 30 or 33, respectively, to Title 38, U.S. Code)
00214 (this option does not apply to spouse or child, only the Member).
Office Use Only
Member Discharge Date: Received by:
Certificate of Eligibility or DD214:
90 Days Active Duty: Received Date: