Term Year:
NAME: ______________________________________________________________________________________
Last First Middle
Are you a:
SSN of Student: __________________________ Potsdam ID: _______________________________
VA Dependent Code #: ____________________ (SSN OF VETERNAN- ONLY CHAPER 35)
Address: ______________________________________________________________________________________
Street City
Phone: _______________________________ Email: ____________________________________
Check the VA Benefits Program you are using or wish to use:
Is this a change of VA Benefit chapter from the previous semester?
Benefit Status:
Type of Program/ Training:
What is your major?
Are you currently Active Duty?
Have you changed your major and/ or program since your last certification request?
If yes, VA Form 22-1995 or 22- 5495 (CH 35) must be accompany this form.
1. I will report any registration changes (add, drop, S/U, withdrawal, etc) to the certifying official.
2. I will notify the certifying official if I stop attending class (s).
3. I will notify the certifying official if I change my major or degree program.
4. I understand that grades “W” and “U” may result in reduced payment from VA.
5. I understand that classes scheduled to meet for less than a normal semester term dates may be paid at a different rate based on the number of
credits and the length of the class.
6. I understand that repeated classes for which I have received a grade cannot be used for my certification.
7. I understand that if I fail to comply with the above, it can result in an over or underpayment of benefits. VA will hold me responsible for
overpayment of my education benefits.
8. I would like to share my SUNY Potsdam e-mail with Operation Military Support (Potsdam Student Group)
My signature below indicates that I understand the above guidelines and that I must complete a new Veterans Certification Request
form each semester of attendance that I wish to receive benefits.
Completion of this form authorizes SUNY Potsdam to provide required information and to certify your enrollment at Potsdam for the specified semester to
the U.S. Department of Veterans Affairs (VA). Fax 315-267-3268 or Mail: SUNY Potsdam Student Success Center, Potsdam, NY 13676.
It is your responsibility to keep VA and SUNY Potsdam informed of changes in your contact information.
STATEMENT OF UNDERSTANDING (Please Initial each line.)
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