This form must be completed and returned to the Veterans Services Office 30 days prior to the beginning of EACH semester.
Forms returned late may cause a delay in the payment of benefits. Inaccurate/incomplete information my cause delay or termination of your benefits.
NOTE: Please use the TAB key to change category.
ENTER key will submit your form.
Contact Information:
FULL NAME:
TELEPHONE #
SOCIAL SECURITY #:
VA FILE #:
STUDENT ID #
MAILING ADDRESS
CITY:
ZIP CODE:
EMAIL ADDRESS:
VA Benefits Chapter (Check one):
CHAPTER 30 (Montgomery GI Bill)
CHAPTER 35 (Survivors & Dependents)
CHAPTER 1606 (Montgomery GI Bill - Selected Reserve or National Guard)
CHAPTER 1607 (Reserve Education Assistance Program - REAP)
ARE YOU CURRENTLY ON ACTIVE DUTY?
YES NO
SEMESTER FOR WHICH BENEFITS ARE BEING REQUESTED: (Check One)
FALL WINTER SPRING SUMMER
PROGRAM OF STUDY AT USM (Degree/Major)
Please list below the courses you are enrolled in for which you are requesting
certification for VA Educational Benefits:
COURSE CODE:
COURSE TITLE
SEMESTER BEGIN / END DATES
CREDITS
Thank You!
Please click Submit This Form button to send your request.
