Instructions: fill out form, choose ‘print’ icon then ‘save as pdf’ and email form from your device to firstname.lastname@example.org
Veterans Affairs Responsibility Form
Student’s Name: _______________________________________ Student ID #: _____________________________
Mailing Address: ___________________________________________ Telephone Number: ___________________
Email Address: _________________________________________________________________________________
The Veterans Administration requires that all recipients of educational benefits maintain academic progress towards
their degree. Listed below is a summary of current VA recipient’s responsibilities.
Please read and initial. Sign and date. Email ____________________________@______________________________
I understand that all classes I enroll in must be required for the degree/program of record that I am pursuing.
I understand that any additional classes not in my degree program cannot be certified for veteran’s educational
benefits, unless this is your last semester. Date of Graduation _____ / _____ / ______
I understand that if I withdraw from a class (W), RPCC must report this grade to the VA along with my last date
of attendance. This grade will not impact my GPA.
I understand that if I stop attending a class, RPCC must report my last date of attendance.
I understand I could be responsible for the repayment of VA educational benefits associated with withdrawing.
Repayment includes book stipend, monthly housing allowance, and/or tuition & fees monies.
I understand that it is also my responsibility to understand all aspects of my benefit. I can contact the RPCC
Certifying Official, the VA (888-442-4551), or the VA website (www.gibill.gov) for more information.
Course(s) I will be withdrawing from: CRN: _________________ Course(s) Name & Number ______________
CRN: _________________ Course(s) Name & Number ______________
MY SIGNATURE INDICATES THAT I UNDERSTAND THE VETERANS RECIPIENT RESPONSIBILITIES AS OUTLINED IN THIS
_________________________________________________ __________________ __________________
Signature Date VA Chapter
VA School Certifying Official ____________________________________ Date _______________
Course Reduction: Initial hours certified to VA _______________ After withdrawal _____________
Office of Financial Aid & Scholarships