Chapter 33 ~ The Post 9/11 GI Bill - Office of the Registrar

Chapter 33 ~ The Post 9/11 GI BillQUARTERLY VETERANS BENEFIT REQUEST FORMPlease complete this form and submit/e-mail it to the Veterans Services Department in the Office of the Registrar.STUDENT INFORMATION:Quarter:20_____ Sessions (Summer Only):Name: VA File # Perm #Check this box if any of your contact information has changed since last quarter. If it has, please fill out the following section.Local Address:Street Apt # City State ZipMailing Address:Street Apt # City State ZipPhone: ( ) Primary E-mail:BENEFIT INFORMATION:Please check the type of veterans’ educational benefit that you are requesting:CHAPTER 33: Post 9/11 G.I. Bill (Please include a copy of your COE-Certificate of Eligibility from the VA)I am a DEPENDENT receiving Chapter 33 benefits. (Please include a copy of your COE)Please check one of the following:Yes __ No __ This is the first time that I have applied for Veterans benefits.Attached is my Application for Veterans Chapter Benefits (22-1990)I have already submitted my Application for Veterans Chapter Benefits with the VA.Yes __ No __ I am a continuing/returning Veterans Chapter benefits recipient from last quarter, or a previous term.Yes __ No __ I am a transfer student and received Chapter benefits from my previous school.If yes on above: Attached is my VA Change of Program or Place of Training form (22-1995)Yes __ No __ I have submitted my COE to UCSB Veterans Office or it is attached to this document.Yes __ No __ I receive Tuition Assistance from the US Military.Yes __ No __ I receive the California College Fee Waiver Plan Aor Plan BMonths of remaining entitlement (if known):For office use only:Eligibility % ___________Insurance Waived Yes __ No __Graduate______ Undergrad ______Resident _______ Non-Resident _____CVA-B Yes ____ No ____~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Education Fee ___________Non-Resident Tuition ___________Tuition Total ___________Reg Fee & Campus Based Fees ___________Insurance___________L&S Fees___________Course Fees ___________Fee TotalTuition and Fee Total Certified______________________DateDatePriority Reg_____ Saved Cert_____D22 Screen (if new)_____ Submitted Cert_____D18 Screen_____ Sticker_____VA Excel Master_____ Complete Audit_____~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Tuition Paid by VA:Date: _______________ Amount: ______________Adjustment/Amendment:Date: _______________ Amount:_______________Macintosh HD:Users:secondaccount:Documents:Microsoft User Data:Saved Attachments:2.5.10 Ch 33 VBRF.docLast updated 2/8/2010

Chapter 33 ~ The Post 9/11 GI BillQUARTERLY VETERANS BENEFIT REQUEST FORMEnrollment Information:Indicate your Major (or Double Major):Minor:I intend to request certification for _____ units for this quarter. By signing this form, I acknowledge that I amsubmitting my intent to enroll. I am aware that I must notify a VA program representative in the UCSB Office ofthe Registrar if my actual enrollment is less than the enrollment I have submitted. I further understand that anymandatory course fees are eligible for reimbursement by the VA. It is my responsibility to report anysuch fees to the UCSB Veterans office for certification.Class Level:FreshmanSophomoreJuniorMA, Grad StudentPhD, Grad StudentDo you expect to graduate this quarter?SeniorNoFor more detailed information, refer to www.gibill.va.gov or contact the VA directlyat 1.888.442.4551STUDENT STATEMENT OF CERTIFICATION:I agree to notify the Office of the Registrar, Veterans Educational Benefits unit, atthe University of California at Santa Barbara immediately of any change in units orprogram status, including termination of my enrollment. In the event that I receive anoverpayment from the U.S. Department of Veterans Affairs as a result of my negligencein reporting any changes of status, I agree to repay the amount of such overpayment tothe U.S. Department of Veterans Affairs. I also agree to only request Veteran’s Benefitcertification for units which fulfill my major/degree requirements. In the event that anysaid units are found unnecessary for my degree/major program, I agree to repay theVeterans’ Administration the amount which is owed to compensate for those uncertifiableunits. I further agree to supply said office with an Academic Advisors approvalquarterly for my registered units.YesStudent’s SignatureDateReturn this completed form to:UCSB Office of the RegistrarAttn: Veteran’s Benefit Program Unit1101 SAASBSanta Barbara, CA 93106-2985For questions, please contact:RegVeterans@sa.ucsb.edu or (805) 893-8905Macintosh HD:Users:secondaccount:Documents:Microsoft User Data:Saved Attachments:2.5.10 Ch 33 VBRF.docLast updated 2/8/2010