Fill - Free fillable RevocationofPreviouslyAssigned TexasHazlewoodActExemptionHours Thisformmustbesubmittedtotheinstitutionwherethebenefitiscurrently beingusedtorevokepreviouslyassignedHazlewoodLegacyhours (Northwest Vist PDF form

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RevocationofPreviouslyAssigned

TexasHazlewoodActExemptionHours

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TVC‐ED‐5

Eff.June2016

Page1of1 

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TEXASVETERANSCOMMISSION

Phone:1‐877‐898‐3833or512/463‐3168|TTY/TDD:Dial711|Fax:512/475‐3932|E‐Mail:Education@tvc.texas.gov|Web:www.tvc.texas.gov

AnEqualOpportunityEmployer

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Thisformmustbesubmittedtotheinstitutionwherethebenefitiscurrently

beingusedtorevokepreviouslyassignedHazlewoodLegacyhours

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AneligibleVeteranordesigneewhohasassignedunusedHazlewoodExemptionhourstoachildthroughthe

LegacyActmayrevoketheassignmentofanyunusedhours[TexasEducationCode§54.341(k‐1)].

Veteran’sName:     

 LastName FirstName MI

Veteran’sSSN: DateofBirth://

(MM/DD/YYYY)

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Address:       

 Street City State ZipCode

PhoneNumber:  Emailaddress:________________________

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I(Veteranordesignee) herebyrevoketheassignmentofunusedHazlewood

Exemptionhoursfrom(child) effectiveattheendofthecurrentacademicterm.

Child’sSSN:  DateofBirth:  //

(MM/DD/YYYY)

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Child’sStudentID#(ifapplicable):  

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I CERTIFY THAT THE INFORMATION  ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND

BELIEF.

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Veteran’s/Designee’sSignature: Date: 

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‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐BelowistobecompletedbyNotaryPublic‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

STATE 

CITY 

COUNTY  

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SWORNTOANDSUBSCRIBEDBEFOREMEONTHISTHE DAYOF ,  

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 

SEAL NOTARYPUBLIC

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 

 DATECOMMISSIONEXPIRES

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RevocationofPreviouslyAssigned TexasHazlewoodActExemptionHours Thisformmustbesubmittedtotheinstitutionwherethebenefitiscurrently beingusedtorevokepreviouslyassignedHazlewoodLegacyhours (Northwest Vista College)

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