800 Mickelson Dr.
Rapid City, SD 57703
605-394-5116 Fax
Veteran Change of Benefit Declaration
Student’s Name: Student ID#:
Mailing Address:
S t reet Ci t y , Stat e Zi p
Phone Number:
_________________ _________
Benefits Change starting Semester (Check One):
(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)