RevocationofPreviouslyAssigned
TexasHazlewoodActExemptionHours
TVCED5
Eff.June2016
Page1of1 
TEXASVETERANSCOMMISSION
Phone:18778983833or512/4633168|TTY/TDD:Dial711|Fax:512/4753932|EMail:Education@tvc.texas.gov|Web:www.tvc.texas.gov
AnEqualOpportunityEmployer
Thisformmustbesubmittedtotheinstitutionwherethebenefitiscurrently
beingusedtorevokepreviouslyassignedHazlewoodLegacyhours
AneligibleVeteranordesigneewhohasassignedunusedHazlewoodExemptionhourstoachildthroughthe
LegacyActmayrevoketheassignmentofanyunusedhours[TexasEducationCode§54.341(k1)].
Veteran’sName:  
LastName FirstName MI
Veteran’sSSN: DateofBirth://
(MM/DD/YYYY)
Address:   
Street City State ZipCode
PhoneNumber: Emailaddress:________________________
I(Veteranordesignee) herebyrevoketheassignmentofunusedHazlewood
Exemptionhoursfrom(child) effectiveattheendofthecurrentacademicterm.
Child’sSSN: DateofBirth: //
(MM/DD/YYYY)
Child’sStudentID#(ifapplicable):

I CERTIFY THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND
BELIEF.
Veteran’s/Designee’sSignature: Date:

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐BelowistobecompletedbyNotaryPublic‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
STATE
CITY
COUNTY
SWORNTOANDSUBSCRIBEDBEFOREMEONTHISTHE DAYOF ,

SEAL NOTARYPUBLIC

DATECOMMISSIONEXPIRES