For Office Use Only
Enrollment
Dates CSU IGETC AA/AS/CT
Pending Evaluation:
Units Certified:
CH 33 %:
Amount Transmitted:
Term/Year
Statement of Responsibility
Return to: Veterans Resource Center
Initial Enrollment Adding Course Dropping Course
Name: Student ID#
E-mail Address: CH 35 VA Claim #
Phone No:
Please check the VA Program you are eligible for:
(Chapter 30) Montgomery GI Bill®
(Chapter 33) Post-9/11 GI Bill®
(Chapter 1606) Montgomery GI Bill®
Student Status:
(Chapter 31) Veteran Readiness & Employment
(Chapter 35) Dependents Education Assistance
Continuing Student Education Plan (Major Change)
New Student Include: COE Education Plan DD-214 (Veterans only)
Degree Objective: CT AA AS Major: GE Option (A, B, C)
Only courses applicable towards the declared major on file will be certified.
List all previously attended colleges:
1. 3.
2. 4.
LIST YOUR CLASS
SCHEDULE BELOW:
Course Units
THIS FORM MUST BE SUBMITTED EACH SEMESTER TO REQUEST EDUCATIONAL BENEFITS
Over See Student Responsibilities
Received by: Date: Revised 10/2020
e.g. ENGL 101
4
Total
Used benefits at another school? No Yes: Include VA form 1995 or VA form 5495
Student Responsibilities
Enrollment Certification: Students must submit a Statement of Responsibility form after registering
for courses every semester they are requesting educational benefits.
Short Term Courses: Students must be enrolled full time throughout the whole semester to receive
their full stipend. If you are enrolled in 6-week term or 8-week term courses, your payment may be
affected.
Prior Credit: Students must submit all official transcripts from any previous college before the end of
their second semester. If all transcripts have not been received, MSJC cannot and will not certify any
courses to the Department of Veterans Affairs until the evaluation process has been completed
Schedule Adjustments: You must report any changes in your school schedule to the Veterans
Resource Center (i.e. Adds or Drops).
Education Plan: You must obtain a comprehensive Education Plan from the Veterans Counselor to
request the processing of your educational benefits. You must have a current educational plan on file with
the Veterans Resource Center at all times.
Withdrawing From a Course: You must report any grades of = “W” (Withdrawal) to the Veterans
Resource Center. VA Payment to you is based on “pursuit” of your program so you must be enrolled,
attending, and successfully completing your courses to be eligible for VA benefits. All grades of “W” will
be retroactively reported to the VA and may result in the retroactive loss of benefits.
Fees Not Covered by VA: You are aware that you will be financially be responsible for payment of
fees not covered by the VA. This includes any NON-RESIDENT charges.
Standards of Progress: Students using educational benefits must maintain satisfactory academic
progress with a minimum 2.0 GPA. Failure to do so may result in an interruption of your certification with
the VA until academic progress has been established.
Schedule of Fees: Fees are due within four days of registration (including holidays and weekends).
Same day pay begins a week prior to the start of the semester. Refer to the Important Semester Dates via
www.msjc.edu.
Processing Time: During peak processing times, the School Certifying Officials may require up
to 3-4 weeks for processing time. Therefore, it is important to submit your SOR the same day you register.
By signing the document, you have read and understand the Student Responsibilities.
Signature Date
GI Bill® is a registered trademark of the U.S. Department of Veterans Affairs (VA). More information about education benefits
offered by VA is available at the official U.S. government Web site at www.benefits.va.gov/gibill