VETERANS & DEPENDENTS BENEFITS AUTHORIZATION FORM
Complete this form for the academic year 2018-2019
Email completed form to: Registrar@stthomas.edu
Debbie Shelito, School Certifying Official -- Phone: 651-962-6725
NAME ST. THOMAS STUDENT ID # ACADEMIC LEVEL
(GRADUATE - UNDERGRADUATE)
**** Chapter 33 students with benefits less than 100%: Be mindful of reaching the VA academic year cap from fall
semester. If cap has been reached, VA will not pay tuition/fees; however, they will pay your housing allowance. You will be using
your time without the benefit of tuition paid. Please take this in consideration when authorizing future semesters. ****
CHECK SEMESTER(S) AUTHORIZING VA BENEFITS
Fall Semester 2018
J-Term 2019
Spring Semester 2019
Summer Semester 2019
VA EDUCATION BENEFIT PROGRAMSELECT ONE
Chapter 30 Montgomery GI Bill
Chapter 30 must verify enrollment monthly to receive payment.
Online www.gibill.va.gov/wave or by telephone 877-823-2378
Chapter 31 Vocational Rehabilitation
VA Counselor’s Name
Chapter 33 Post 9/11 GI Bill
Check if Active Duty
- or -
Check if Spouse of Active Duty Veteran
Chapter 35
Dependents Education Assistance
(veteran disabled)
Veterans File Number or Social Security Number
(Required first time new student)
Chapter 35 Fry Scholarship
(veteran died line of duty)
Veterans File Number or Social Security Number
(Required first time new student)
-or-
Choose one:
Chapter 1606 Select Reserve
Federal Tuition Assistance
Chapter 1606 must verify enrollment monthly to receive payment.
Online www.gibill.va.gov/wave or by telephone 877-823-2378
Apply at least 60 days prior to start of term.
ARE YOU CHANGING PROGRAMS OR PLACE OF TRAINING?
Yes, I am changing program or place of training.
If yes, Chapters 30, 33 1606 complete VA form 22-1995 located at www.vets.gov.
If yes, Chapter 35 complete VA form 22-5495 located at www.vets.gov .
CHAPTER 33 RECIPIENTS PROVIDE A CURRENT STATEMENT OF BENEFITS EACH ACADEMIC YEAR
.
Yes, Statement of Benefits attached.
Then anticipated funds can be applied to your account prior to VA submitting payment.
Obtain statements at www.vets.gov or award letters can be provided to School Certifying Official
The Yellow Ribbon program is available to:
Chapter 33 recipients at the 100% eligibility rate
Veterans that are not on active duty
Students that have not had a break in attendance
~~~~~~~~~~
I authorize my enrollment information for the above-specified term(s) be certified with the VA.
It is my responsibility to notify the School Certifying Official of any changes in my enrollment.
Any enrollment adjustment I make may result in a change to the benefit amount I receive from the VA.
I am responsible for any overpayment created by these adjustments and all University bills if funding is withheld.
I certify that the courses for which I have enrolled meet my degree requirements.
I understand that the VA will not pay for courses that do not meet my degree requirements and the VA will not pay for
audited courses.
Signature: __________________________________ Date: ____________________________
If unable to obtain an electronic signature thru Adobe, sending this form from your St. Thomas email account will act as your
signature.
Email completed form to: Registrar@stthomas.edu
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