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):
S
Print Full Name (as it appears on your college student application/records):
Would you like to be contacted of your status
change?
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
Military personnel
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).
Signature: Date:
Office Use Only
Member Discharge Date: Received by:
Certificate of Eligibility or DD214:
90 Days Active Duty: Received Date:
Coded AB13:
