800 Mickelson Dr.
Rapid City, SD 57703
605-348-2204 Fax
Veteran Benefit Declaration
Student’s Name: Student ID#:
Mailing Address:
S t r eet Ci t y , Stat e Zi p
Phone Number:
_________________ _________
Please select the Benefit Program you will be using for your Program:
Chapter 1606 Chapter 30 Chapter 31 Chapter 33 Chapter 35
Selected Reserve Montgomery Bill VA Voc. Rehab Post 9/11 Bill Survivor/Dependent
Please check area of service related to the Veteran Benefits you are receiving
Veteran of __________________________ Reserves
Active Duty with ______________________ National Guard (State _________)
Spouse or Dependent of Veteran who is deceased Spouse or Dependent of Veteran/Active Duty
Veteran/Active Duty or Spouse/Dependent of Veteran/Active Duty who has suffered service related injury/illness.
*If Taking Corporate Education Class:
Course: Class Dates:
By signing below, I verify that the above information is correct and that I intend to utilize the declared benefit for all semesters
pursuing my program of study. If I choose to stop benefits, I will notify the Registrar’s Office in writing.
Student Signature Date
School Certifying Official Use Only
Student activated for certifications in VAOnce (Initial Certification Processed) _________ (initials) _______________ (date)