Instructions: This form must be completely filled out each semester and submitted to the Veterans Service Office in order to be certified for VA education benefits.
STUDENT INFORMATION
Student ID Number: Full Name: Current mailing address: City: State: Zip:
Continuing student New student Transfer student
ACADEMIC INFORMATION
Semester to be certified: Full term credits in class: Full term credits online: Partial term credits (hybrid, late start, weekend, accelerated, etc.): Partial term credits in class Partial term credits online
Dates of partial term courses (include start and end date of each partial term class and the course #. E.G. ACC 115 - Starts 3/5 Ends 5/2.):
NOTE: PARTIAL TERM COURSES MAY REDUCE YOUR VA BENEFITS!!
Degree Objective:
If this is a change, please stop by the Veterans Service Office to complete the necessary paperwork. If you’re unsure what degree plan to pursue, please stop by the Veterans Service Office to discuss your options, as VA pays only for courses which are part of your degree plan.
BENEFITS INFORMATION (Please check the benefit type you’re receiving)
Chapter 30 – Montgomery GI Bill Chapter 32 – Veterans Educational Assistance Program (VEAP) Chapter 33 – Post 9/11 GI Bill Chapter 35 – Dependent’s Educational Assistance (DEA); VA Claim No: Chapter 1606 – Montgomery GI Bill-Selected Reserve Chapter 1607 – MGIB-Reserve Educational Assistance Program (REAP)
If you drop or change classes resulting in a reduction in your tuition, you may incur a financial obligation to CCA if a refund was issued to you based on VA tuition payments.
We automatically extend deferments to all students who have applied for VA education benefits. By typing your name in the signature block below, you acknowledge that you are responsible for your tuition and fees should VA deny your application for benefits. You are also acknowledging that you understand the above information and that the information you provided is accurate.