You are required to complete this form each semester to request benefits
Veteran’s Statement of Responsibility
Check One:
Last First M.I.
Street City State Zip
Attending another college concurrently?
Check one:
Per V.A. Regulations
I understand that the V.A. will not pay for the following courses:
Courses I have not completed successfully ( some “D” grades are useable)
Courses not
listed on the V.A. Student Educational Plan
Current Student Educational Plan must be on file
Only courses on Student Educational Plan can be certified for benefits
(I realize this may require release of confidential academic information to necessary institutions)
I will notify San Bernardino Valley College's Veterans Certifying Official of any change in my
schedule, and understand that misrepresentation of my records of falsely certifying my
classes may cause my Veterans eligibility to be denied or decreased.
Student’s Signature: ___________________________________________
ADVANCED PAY REQUEST
Request for advance payment may only be submitted if you are allowed to register for classes 45 days prior to the start of term.
Advance payment is not available under Chapter 33.
Signature for Advance Pay Request _______________________________________________
White/Original Copy – VA Office Yellow Copy – Student
SBVC A&R ROOM 100, 4/2016
FOR OFFICE USE ONLY
Accepted By: _______________
Date Processed: ____________
Registration Statement
Education Plan
Certificate of Eligibility
Other:_____________________
Number of units for which you will be enrolled in?
Start Date
Check One:
Year
Check One:
Date
Name
Address
Social Security Number Student ID #
Cell Phone
Email
Work Phone
List all colleges:
Major
Transferring to
AS/AA
BS/BA
Certificate
End Date
Ch 30 Ch 31 Ch 33 Ch 35 Ch 1606 1607
Fall Spring Summer
Yes No
Current Student New Student
Please check this box: I request San Bernardino Valley College to submit
a certification of V.A. Educational Assistance for this term on my behalf.
Yes, I have previous education and training. All academic transcripts from the previous institutions need to be submitted to Admissions and Records
No, I do not have previous education or training.
click to sign
signature
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click to sign
signature
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