Veterans Request for Enrollment Certification
Complete only AFTER you have stabilized your enrollment for the next semester
Veteran/Military Benefit Information
Benefit to be certified:
Ch. 30 Montgomery GI
Ch. 33 Post 9/11
Fry Scholarship
Ch. 31 Vocational Rehab.
Ch. 35 – Dependent/Spouse VA File#________________
Ch.1606 – Montgomery GI - Selected Reserve
If you are a new Ivy Tech student, have you previously received VA benefits at another institution:
*You must report the change to the VA by completing Form 22-1995 (veterans) or 22-5495 (dependent/spouse) via
Term to be certified (check one):
Ivy Tech Community College Enrollment Information
Name of Program:
Degree Type:
Is this a change since last term? Yes* No
Credits Enrolled? * Will you be graduating this term? Yes No
* Classes that do not meet for the full length of the semester are only considered for benefits during the period they meet. The VA will
exclude them during the rest of the semester when determining your rate of pursuit for benefits eligibility. NOTE: Enrollment dates
may vary for these courses and as a result, payment may differ throughout the term.
Are you repeating a course? Yes*
No Course you are repeating:
* Repeated courses can only be certified if a higher grade in that course is required for completion of your current degree
I understand that I am responsible for paying any tuition & fees not paid by the VA.
I understand that I will receive benefits only for courses applying toward my program of study. Courses not listed as a
requirement for program completion will not be certified and I will not receive benefits for them.
Any change in status (dropping/adding courses, address & phone number changes, etc.) must be reported immediately
to the Certifying Official. Changes in enrollment after certification may result in an underpayment or overpayment of
I understand that after prior credit has been evaluated (military transcripts/prior college), any credit awarded for class(es)
that I’m currently enrolled and certified for by the VA will be decertified, which may result in an overpayment of benefits.
I understand that I am liable for any overpayment(s) that I might receive from the VA.
I understand that any unsatisfactory progress will be reported to the VA.
I understand that I must complete this form for EVERY SEMESTER I wish to receive VA Educational Benefits. Failure to
complete and return this form as soon as I have finalized my enrollment for the indicated term may cause a delay in my VA
benefits for that term.
I hereby certify that all statements I have made on this form are true and complete to the best of my knowledge and belief.
Signature: ___________________________________________________ Date: _________________________
After completing this form, please print and sign. Return to your Campus Certifying Official
Last Name: First Name:
Street Address:
City: State: ZIP: Telephone:
Email Address: Student ID# (C#):
*Ensure the courses you are taking this semester count toward your new degree program.
click to sign
click to edit