Northeast Iowa Community College | VETERANS WORKSHEET
Name ________________________________________________ Social Security Number______________________
Address __________________________________________________________________________________________
(City) (State)
(Street) (Zip Code)
E mail __________________________________________ ________________________________________
Military Status: Active Family Member Guard Veteran Reserves
Branch of Service ______________________ MOS ________________________ Rank_______________________
VA Program you are applying/eligible for:
Chapter 30 -- Montgomery G.I. Bill (Active Duty) – Service after 7/1/85
Chapter 31 – VA Vocational Rehabilitation
Chapter 32 -- VEAP – Service between 1/1/77 and 6/30/85
Chapter 33 -- Post 9/11 G.I. Bill – Service on or after 9/11/01
Chapter 35 -- Dependent of Veteran _______________________ Veteran SSN ______ Payee #
Chapter 1606 -- Montgomery G.I. Bill (Reserve/National Guard)
Chapter 1607 -- Reserve Educational Assistance Program (mobilized Reserve/National Guard)
1. NICC Program ________________________________________________________________________________
2. Start Term and Year: Fall Spring
Summer
3. Where did you last receive VA benefits? NICC Other College Never (New)
Colleges Attended/Received Benefits _______________________________________________________________
Colleges Attended/Did not Receive Benefits __________________________________________________________
4. Do you intend to be: Full-time Part-time Have you been accepted into your program? Yes No
5. Do you intend on repeating any courses? Yes No Which ones?________________________________
NOTE: Veterans benefits are not paid on courses that you previously completed with a passing grade from NICC or another college.
You must provide the NICC Registrar’s Office with a copy of your official transcript for each college or university you have
previously attended. If the Registrar’s Office has not received transcripts prior to the end of your second semester of
enrollment at NICC, your benefits will be terminated until they are received.
In order to remain eligible for VA benefits, you must maintain satisfactory academic progress which means you must earn
a cumulative grade point average (GPA) of 2.00 or better and attend classes. If you do not attend on a regular basis or
quit attending class, possible termination of your benefits can occur. See the Academic & Attendance Policy for Students
Receiving Financial Aid in the Student Handbook. You will be responsible for any repayment of educational funds
you have already received if termination occurs because of withdrawal or non-attendance.
You will only be paid for those courses that meet degree requirements in the educational program on file with the
NICC Registrar’s Office.
Changes in your address, program of study, withdrawal from college, and adding/dropping courses must be
reported immediately.
IF YOU EXPECT TO RECEIVE BENEFITS UNDER CHAPTER 33, READ AND UNDERSTAND THE INFORMATION ON
THE REVERSE SIDE.
I AM AWARE THAT CHANGES IN MY REGISTRATION MUST BE REPORTED TO THE CAMPUS VA CERTIFYING
OFFICIAL AND MAY ALTER THE PAYMENT THE VA WILL AWARD ME. I understand that I will be liable for any
________________________
overpayment which I might receive from the Veterans Administration.
x__________________________________________________________________
I request G.I. Bill payment for the program I have listed in question #1 (Signature) Date
___________ Copy given to student
Year:
Phone
