REQUEST FOR VETERANS EDUCATIONAL BENEFITS General Information .

Semester:
REQUEST FOR VETERANS EDUCATIONAL BENEFITS
This version of the VA benefits form is intended for use by first semester GI Bill® students only.
General Information
Last Name
First Name
Middle Name
□ Yes □ No
Is this a new address to report to VA?
Street Address
City
State
JMU Student ID #
Preferred Phone #
Zip
JMU Email
Veterans Affairs Education Benefits
Indicate your VA Benefit Chapter:
_________________________________ (ex – Post 9/11, DEA (need file #), MGIB Selected Reserve, REAP)
Post 9/11 Recipients Only: Tuition Classification, Choice Act Section 702 and Scholarships
Tuition Classification and Choice Act (Click here for more information on the Choice Act):
Are you In-state or Out-of-State for tuition? (based on JMU’s decision) □ In-state □ Out-of-State (Ch. 33 only pays your % of in-state rate)
If Out-of-state, do you qualify for the Choice Act? □ Yes (provide COE and service member’s DD-214) □ No (provide written proof stating why)
Scholarships:
We are required to report the net cost of in-state tuition & fees after the application of funds being sent to JMU that are designated for the sole
purpose of defraying tuition and fees. These funds include waivers, scholarships, aid, and assistance. Title IV loans and grants (Pell,
sub/unsubsidized and Parent Plus loans) are not considered.
Are you receiving any scholarships and/or tuition/fee specific funds? □ Yes
□ No If yes, please contact us and provide proof
List scholarship(s) or T/F funds: ____________________________________________________________________________
Do you receive any of the following:
□ ROTC
□ MSDEP
*If ROTC, it is: □ scholarship □ stipend
□ Military Federal T/A
If ROTC scholarship, it is for:
□ Virginia State Tuition Assistance
□ tuition and fees
□ Tuition Waiver
□ room and board
□ Graduate Assistantship
Have you previously received VA benefits while attending another university/college?
□ Yes, I received VA benefits while attending: _______________________________________
(Name of School)
□ No, I have never received VA benefits while attending another institution.
If yes, have you submitted VA Form 22-1995
or 22-5495 (Chap 35)?
□ Yes
□ No (If no, please contact us)
Have you submitted all transcripts, including DD-214 and Military transcript if you are the service member? □ Yes
Are you taking courses at another school while enrolled at JMU for this term? □ Yes
□ No
□ None of the Above
□ No
(If yes, contact us ASAP)
Academic Information
Indicate your major and degree type: _________________________
Anticipated Graduation Date: ___________________
If undeclared, only general education courses can be reported to VA
Does your major require a concentration or track? (if yes, it must be declared) □ Yes (list) _________________
□ No
Enrollment Information
List the courses for which you are currently pre-registered and indicate with a checkmark in the appropriate columns below which
requirements (General Education, major, etc.) are being fulfilled. Course enrollment must apply to requirements for graduation.
Course Information:
Subject
Course #
Credit Hour Total:
Credit
Hours
Requirement Fulfilled:
Other requirement
General Education Clusters
Start and End Dates
Major
1
2
3
4
5
Office Use Only: _____Sem _____1st Bl _____2nd Bl
_______Res
Minor
(Please specify. Ex – degree,
honors, university elective, pre-req
course., pre-professional program)
_______Dist $___________T/F
*Enrollment that includes 8 week block sessions may affect the amount VA can pay. Please see School Certifying Official for explanation
Please be advised that VA benefits are dependent upon receipt of this form. Remit this form
to the Registrar’s Office immediately upon completion.
Continue to page 2
Obligation to James Madison University and Veterans Affairs
THIS IS IMPORTANT INFORMATION REGARDING YOUR VA EDUCATION BENEFITS.
PLEASE INITIAL BESIDE EACH STATEMENT TO CONFIRM THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION.
____ I understand that I must have all majors, minors, concentrations, and tracks declared in order for any courses applicable to those
programs to be paid for by VA. For example: if a course is listed for a minor, the minor must be declared or be in the process of
being declared before VA will pay. VA will not pay for recommended courses or courses for a future program.
____ I understand that VA determines eligibility for education assistance in all cases.
____ I understand that I must submit the JMU Request Form each semester for payments. After the first semester, the form is
emailed to the student directly during advance registration. I also must promptly report any changes in my academic program
(major, degree, etc.), hours of enrollment, graduation date, or address to the VA School Certifying Official in the Office of
the Registrar.
____ I understand that course fees and differential tuition charges are reported at least one month after the start of the term and are
only payable by VA if the course is required for graduation (for Post 9/11 students only).
____ I understand that changes in course enrollment after the last day to add/drop courses may result in the retroactive loss of benefits
from the date of the change or could revert back to the first day of the term and may result in a student’s debt to VA.
____ I understand that I must be formally declared in an academic degree program (major, minor, etc.) or an approved certificate
program by the end of my second term of enrollment in order to continue receiving VA benefits. Undeclared majors can only
receive benefits for general education courses.
____ I understand that I can only receive benefits for courses required for my degree or certificate program and that I must make
satisfactory progress toward graduation/completion.
____ I understand that VA will not pay for non-attendance nor for courses that I audit, take without credit, or do not successfully
complete, and that VA will hold me responsible for the repayment of the debt.
____ I understand that withdrawal from courses and subsequent grades of ‘W’, ‘WF’, or ‘WP’ will result in a student debt with VA. DO
NOT withdraw from any class or classes without talking to someone in the VA Office at JMU (located in the Registrar’s Office)
____ I understand that advisor error or misadvising is not an acceptable reason for taking courses not applicable to my program.
____ I understand that repeating a course may or may not be payable by VA and could impact my fulltime status for my benefits
(Contact VA School Certifying Official for policy explanation.)
____ I understand that enrollment in mini term (block or eight-week and summer session) courses may be paid at a different rate as
determined by VA based on the number of credit hours and the length of the course, unless my enrollment includes 12 semester
credits (the amount considered full time for undergraduate students during a regular semester).
____ I understand that full time status is different for summer enrollment. (Contact VA School Certifying Official for policy explanation.)
____ I understand that any transfer credits must be reported to JMU immediately after course completion.
____ I understand that grades of ‘incomplete’ must be completed by the end of the next semester or VA benefits may be
reduced or interrupted.
____ I understand that if I am in the National Guard or Reserves and using Tuition Assistance / Tuition Assistance Top-up and the GI
Bill concurrently, I cannot have both benefits cover the same course. It is my responsibility to ensure that there is no
duplication of federal benefits.
____ I understand that if I am eligible for Chapters 30, 1606, or 1607 (does not apply to Post 9/11 GI Bill) that I am required by VA to
verify my enrollment on the last calendar day of every month in which I attend courses. This can be accomplished by visiting
http://www.gibill.va.gov/wave or by calling their toll free number: 1-800-823-2378. Failure to perform this step will result in delayed
payment by VA.
____ I understand that I accept full responsibility for information disclosed on this form. This information is used to certify my enrollment to VA.
____ I understand that if I do not comply with VA guidelines, my education benefits may be discontinued and I may be subject
to VA debt.
____ I understand that my signature authorizes the School Certifying Officials to release my enrollment transactions,
academic standing, grades, graduation, etc. to either the Department of Veteran Affairs or Department of Veteran
Services for the purposes of processing payments or audit of record.
____________________________________
Student Name (Printed)
________________________________________________________
Student Signature
_______________________
Date
Signed and completed form may be (1) faxed (540-568-5615), (2) scanned and emailed ([email protected]), (3) delivered to Student
Success Center Room 5300, or (4) mailed to:
VA School Certifying Official
GI Bill® is a registered trademark of the U.S.
Office of the Registrar
Please visit our website
Department of Veterans Affairs (VA). More
information about education benefits offered by VA
738 South Mason Street
for additional information:
is available at the official U.S. government Web site
Student Success Center, Room 5300
www.jmu.edu/registrar/veterans
at http://www.benefits.va.gov/gibill."
MSC 3528
Updated 3/2016
Harrisonburg, VA 22807