VA REQUEST FOR CERTIFICATION
 

NAME __________________________________________________________________    
                           LAST                                                                          FIRST                                          MI

Student ID #  _________________________  VA FILE NUMBER ___________________

MAILING ADDRESS ______________________________________________________

_______________________________________________________________________
  CITY                                                                        STATE                                                ZIP CODE

PHONE: _________________________________________________________

CLASS STATUS _____FR   ____SOPH   ____JR   ____SR   ____ GRAD

MAJOR_____________________________  MINOR_________________________
HAS YOUR MAJOR CHANGED? ________
(If yes, you must file a 22-1995 or 22-5495 form in the Records Office.)

VA BENEFIT:
____ CHAPTER 30        (MGIB -  ACTIVE DUTY)
____ CHAPTER 31        (VOC REHAB)
____ CHAPTER 32        (VEAP)
____ CHAPTER 35        (SURVIVORS/DEPENDENTS)
____ CHAPTER 1606    (MGIB - NATIONAL GUARD _____ RESERVES _____)

Please certify me for the following terms:

____ FALL 2008                          ____ SUMMER I 2009
____ SPRING 2009                      ____ SUMMER II 2009
____ MAY 2009                

STATEMENT OF UNDERSTANDING:

I am fully aware that my certifications will be sent electronically through the VA's secure website.
I understand that I must report any changes to the Coordinator of Veterans Affairs immediately.  I am aware that changes in my enrollment status may alter the payment the VA will award me.  I also understand that I will be held liable for any overpayment that I might receive from the VA.
 

SIGNATURE___________________________________  DATE___________________

RETURN TO:     Records Office
                          Station 6040
                          Montevallo, AL  35115