Veterans Educational Benefits Request Form

Privacy Act of 1974, Public Law 93-579

In accordance with Section 1.576 (b) of the Privacy Act of 1974 (Public Law 93-579), I hereby authorize the SUNY Broome Community College Veterans and Military

Affairs Office to release or disclose any information contained in my SUNY Broome veterans record and/or Veterans Administration. The purpose of this authorization

is for my VA educational benefits. This authorization will remain in effect during the period of my application and attendance at SUNY Broome and for a period of

time my records are subject to VA review.

INSTRUCTIONS: Please complete this form and return to Veterans and Military Affairs, SS 102.

Section 1. Student Information Email:_____________________________

Last Name First Name MI

Broome ID B Phone DOB

Address :

City: State: Zip Code: Is this a new address since last request? [ ] Yes or [ ] No

SECTION 2. Benefit Information

Check Semester requesting benefits:

[] Fall [] Winter [] Spring [] Summer Year_____ Are you Graduating This Term: YES / No (circle one)

Note: A separate form must be completed for each semester.

Please check the appropriate category: [] Ch 33 Post-9/11 GI Bill®

[] Ch 30 Montgomery GI Bill® – Active Duty [] Ch 1606 Select Reserve and National Guard

[] Ch 1607 REAP Reserve Ed. Asst. Program [] Ch 31 Veterans Vocational Rehabilitation

[] Ch 35 Survivor/ Dependent Educational Asst. VA Claim Number_____________________

GI Bill® is a registered trademark of the U.S. Department of Veterans Affairs (VA)

Chapter 30, Chapter 1606/1607 recipients must report school attendance to the Dept. of Veterans Affairs at the end of each month in

order to receive payment. Call 1-877-823-2378 or go to www.gibill.va.gov/wave/.

Have you ever received VA education benefits before at a different school?

[] No

[] Yes Name of School________________________ Semester/Year____________________

If Yes, Must also complete VA Form 22-1995 Chapter 35 Must complete VA Form 22-5495

HAVE YOU SUBMITTED YOUR OFFICIAL TRANSCRIPTS FROM ALL PRIOR INSTITUTIONS? (Circle one) Yes No

You MUST submit official transcripts from ALL former institutions by your second semester of enrollment at SUNY BCC and meet with your

Academic Department for transfer evaluation of credits.

Section 3. Degree information

Is this different than previously reported? [ ] Yes [ ] No

Major: Are any of your classes held solely Off-Campus this semester? [ ] Yes [ ] No

*** Attach copy of your Concise Class Schedule ***

Classes that do not meet for the length of the semester are only included during the period they meet. The VA will exclude them

during the rest of the semester when deciding how much you will be paid. NOTE: Enrollment dates may vary for these courses and as

a result, payment may be different than expected. Non Resident Tuition charges will not be covered by Chapter 33 benefits.

** VA DOES NOT PAY FOR AUDITED, COURSES PREVIOUSLY PASSED, PREREQUISTE COURSES, COURSES NEVER

ATTENDED OR COURSES THAT DO NOT COUNT TOWARD YOUR DEGREE AT SUNY Broome Community College.

All students not attending, withdrawing from, adding, or changing classes are responsible for notifying the Veterans and Military Affairs Office.

Change in course enrollment/attendance after certification has been submitted to the VA may result in the retroactive loss of benefits. Loss of

benefits could revert back to the first day of class leaving you with an unpaid bill owed to the college.

CONTINUED ON REVERSE

Section 3. Degree information (cont’d)

Student Responsibilities:

- Eligible Veterans, Dependent of Veterans and Active Duty military personnel should only be charged in-state tuition. Please notify the

Veterans and Military Affairs Office if you are charged Out of State Tuition.

-Regardless of the courses you enroll in, the SUNY Broome Veteran’s Certifying Official can only certify enrollment in courses that are

required for your SUNY Broome degree/certificate as defined in the SUNY Broome catalog.

-Inform the Veterans and Military Affairs Office immediately of any changes to class schedule or nonattendance of any class(s). Failure to report

non-attendance or changes in your enrollment may result in suspension or termination of your VA Education Benefits and leaving you with a balance

owed to the college or Veterans Administration.

-Online remedial (developmental) courses cannot be certified to the VA.

-Most Hybrid and Independent Study courses are considered distance learning by the VA.

-If you are placed on academic probation or academic dismissal, SUNY Broome is required to report this status to the VA.

-Understand that Academic Dismissal may terminate benefits.

-Report to Veterans and Military Affairs Office and request VA Educational Benefits each semester to receive benefits.

-It is recommended that you apply for federal student aid by completing a Free Application for Federal Student Aid at www.fafsa.gov. For SUNY

Broome to receive your application data you must include our school code, 002862, as one of the schools you plan to attend.

-You are liable for any overpayment with the Veterans Administration and or balances owed SUNY Broome.

-Furnish the college with your military transcript(s) in addition to official transcripts from all college/universities previously attended and

meet with your academic department to evaluate and grant prior credit as appropriate.

-It is the responsibility of the U.S. Department of Veterans Affairs to approve applications for Veterans Educational Benefits and to make

decisions regarding payment, issuance of checks, and eligibility.

-Your signature on this form authorizes release to the US Department of Veterans Affairs all of your student education records maintained by SUNY

Broome Community College including, but not limited to, your Social Security Number.

-Specific questions regarding payment or eligibility for Veterans Education Benefits, contact the U.S. Department of Veterans Affairs at (888) 442

4551.

*** Please Note ***

Veterans and Active Duty military personnel with special circumstances are encouraged to communicate these, in advance if possible, to

their instructors at the start of each semester.

You receive benefits based on attending classes. If you stop attending your class(es) the VA will be notified and your benefits may be

retroactively reduced leaving you with a debt to the VA and SUNY Broome. You must attend through the last day of classes to receive full

entitlement, even if you feel you can not pass the class(es). At the end of each term instructors report the last day of attendance for any

student receiving a failing grade.

Section 4. Student Certification

I am aware that changes in my registration may alter the payment the VA will award me. I understand that I will be liable

for any overpayment I might receive from the Veterans Administration. I also understand that I must notify the Veterans

and Military Affairs Office of any changes in registration by providing the office a copy of my add/drop form.

I am also aware that I must fill out this form each semester after registering for classes.

I understand that it takes 4 to 8 weeks for the VA Regional Office to process my educational benefits and will plan

my expenses accordingly. Payment is usually paid retroactive to the beginning of the semester.

I, ________________________ hereby declare that I have read the terms and conditions to receive Montgomery GI Bill

Education Benefits/Post-9/11 Veterans Educational Assistance Act of 2008.

Failure to comply with these terms may result in debt to SUNY Broome or the Department of Veterans Affairs and

delayed payments.

___________________________________ ________________________

Student’s Signature Date