Instructions: fill out form, choose ‘print’ icon then ‘save as pdf’ and email form from your device to
Veterans Affairs Enrollment Verification Form
Student’s Name: _______________________________________ Student ID #: ______________________________
Mailing Address: ___________________________________________ Date of Birth: ________________________
Telephone Number: ____________________ Email Address: __________________________________________
Enrollment Certification (All classes MUST be in your program of study) Attach Schedule and Degree Audit/Curriculum Sheet.
Fall ________ Spring __________ Summer __________
________ Enrolled Hours ________ Enrolled Hours __________ Enrolled Hours
Indicate the VA Educational Program you will receive benefits under. Please check
_______ Chapter 30 (Montgomery GI Bill-Active Duty)
_______ Chapter 1606 (Montgomery GI Bill Selected Reserve)
________ Chapter 33 (Post-9/11 GI Bill) What is your percentage of eligibility? _______%
______ Check if benefits were transferred from a parent or spouse
_______ Chapter 31 (Voc. Rehab) Case Manager: ___________________________________________
_______ Chapter 1607 (REAP)
_______ Chapter 35 (Dependent) VA File Number: __________________________________________
______ Check if you are receiving Title 29
_______ Louisiana National Guard Service Member
Student Status
First-Time Freshman Transfer Student Continuing Student Readmit Student
Check the box that describes you best
_____ I have never used VA benefits, but I have completed an application for VA Educational Benefits (MUST provide letter of
_____ I have used VA Educational Benefits while attending RPCC.
_____ I am transferring to RPCC this semester and I have completed a Change of Place Training form (MUST provide a copy).
Please initial after reading each statement
________I understand that I MUST Maintain Satisfactory Academic Progress toward my educational degree.
________I understand that I MUST Notify the RPCC Financial Aid Office of any class changes or Withdrawals. Failure to do so may
result in termination of benefits and possibly having to repay initial VA Educational monthly awards.
________I understand that I MUST be enrolled in an approved program of study that leads to a degree or certificate and have all
prior transcripts on file with River Parishes Community College.
________I understand that I will not be paid for courses previously passed at RPCC or other institution.
_____________________________________________ ______________________________
Signature Date
Office of Financial Aid & Scholarships
Gonzales-Westside-Reserve Campuses