DMA FORM 189-E, December 2017
Date Processed: By:
STUDENT PORTION: THIS APPLICATION MUST BE RECEIVED AT THE DEPARTMENT OF MILITARY AFFAIRS (DMA)
NO LATER THAN 90 DAYS AFTER EACH COMPLETION OF A COURSE OR TERM, WHICHEVER OCCURS FIRST. After
completing all lines in the student portion, the applicant must submit this application to the appropriate College Registrar’s Office or
Veterans’ Office for certification of the school portion. Submit an application even if a course(s) is incomplete. Reimbursement is
determined by the resident undergraduate base tuition charged by the University of WI-Madison or the tuition rate at the student’s qualifying
school, whichever is less. Every effort is made to reimburse the student within a month of the term end date. This grant will be suspended if
the student is AWOL or flagged & denied if the student is delinquent in child support or maintenance payments s. 49.854(2)(b), WI Stats.
Social Security Number: -
- Check
Guard Membership: Army
Air
Print Name: Check: Male Female
First Middle
Last
Address where check should be sent: City:
State: Zip:
Birthdate: Academic
Term Dates From:
/ / To: /
/
Month Day Year Month Day
Year
School Name: # of credits anticipated this academic term
I certify that: (1) I will direct all grant questions to the DMA Grant Specialist at 608-242-3159, (2) my school may release this form to
DMA, (3) the application must be received by DMA within 90 days of the term end date & I will call DMA prior to that deadline if I
have not received my reimbursement, (4) a minimum grade point average of 2.0 is required per term, (5) I do not have a Bachelor’s
Degree, (6) I must be an actively drilling WI Guard member, but not an officer, upon the completion of this term, (7) I cannot apply
for this grant simultaneously with VetEd or the WI GI Bill, (8) this grant may reimburse no more than the tuition balance after other
tuition benefits pay (e.g.: Chapter 33, Federal Tuition Assistance or Air Force Tuition Assistance), (9) I may receive up to 8 semesters
of tuition reimbursement, (10) if I do not fulfill my military contract, DMA will pursue recoupment for the grants awarded, (11) most
out-of-state schools & on-line schools do not qualify for this grant. I will contact DMA to inquire if my school qualifies for this grant
or consult the qualifying school list at
http://dma.wi.gov/DMA/support/education
. The grant application is also on this website.
Date: Telephone:
SCHOOL PORTION: After classes are completed , the School’s Registrar or Veteran’s Representative certifies this form for the above
named student & term. The school keeps a copy & submits this application within 90 days of the term completion to: WI Department of
Military Affairs, WIAR-G1-ED, PO Box 8111, Madison, WI, 53708-8111. Upon fulfillment of previously incomplete course(s), adjust the
number of satisfactory credits & the tuition paid, then submit to DMA. Direct questions to the DMA Tuition Grant Specialist 608-242-3159.
School Name: USDOE Federal School Code:
Beginning date of most recently completed term:
/ /
Ending date of most recently completed term:
/
/
Month Day Year Month Day
Year
# of credits satisfactorily completed this term: # of incomplete credits this term:
# of credits earned exclusively on-line this term:
# of University Post-Grad degree credits this term:
IMPORTANT: report if another tuition specific benefit paid this term. Circle all that apply: Chapter 33 / WI GI Bill / Federal Tuition
Assistance / Air Force TA / VetEd /other?
Indicate amount each paid. $
specify other source attach explanation, if necessary
Out of Pocket tuition paid by student for satisfactorily completed courses ONLY: $
(NO Segregated fees, CEUs)
Yes
No
Did the student attain a
minimum grade point average of 2.0 for this term/semester (NOT cumulative GPA)
?
Yes
No
Did the applicant have a Bachelors Degree prior to the completion of this most recent term?
During the term dates on this application, the above named student is in the School of ________________________________________________.
(ie. Business Administration, Engineering, Not applicable, etc.)
Print School Certifying Official Name: Date: Telephone:
DMA STATE BUDGET & FINANCE PORTION:
WISCONSIN NATIONAL GUARD TUITION GRANT APPLICATION
Application in compliance with: Privacy Act of 1974, E09397; WIARNG Regulation #621-7, WI ANG Regulation #53-01 and WI Statutes, Section 321.40.
Completion of form is voluntary; however, lack thereof will prevent grant processing. Personal information will not be used for any other purpose.
MILITARY PORTION:
To be certified by the appropriate WIAR-G1-ED or WIAF-DP WI National Guard Office.
Pay Grade: Unit Code: Enlisted:
/
/ Education Code: ETS:
/
/
Month Day Year Month Day
Year
Certifier’s Signature Date Certified: Comment:
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