800 Mickelson Dr.
Rapid City, SD 57703
605-718-2410
605-394-5116 – Fax
Veteran Change of Benefit Declaration
Student’s Name: Student ID#:
Current
Mailing Address:
___________________________________________________________________________________
S t reet Ci t y , Stat e Zi p
Phone Number:
_______________________________
Program:
_________________ _________
Benefits Change starting Semester (Check One): ☐
Fall
☐
Spring
☐
Summer
_______
___
(Academic Year)
Please select the Benefit Program you will be changing to 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
*Student must include new Certificate of Eligibility and Notice of Basic Eligibility.
**Student must include new Certificate of Eligibility with Change of Benefit Declaration.
***Student will need to have his or her VA Vocational Rehabilitation Counselor submit the authorization of benefits.
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 revoke use of my currently declared benefit starting the effective semester and that I intend to utilize the newly
declared benefit for all remaining semesters for my program of study. By signing I also verify all the above information is correct. If I
choose to stop benefits, I will notify the Registrar’s Office in writing.
Student Signature Date
School Certifying Official Use Only
☐ Student certified for newly declared benefit _________ (initials) _______________ (date)
