YORK COUNTY COMMUNITY COLLEGE

VETERANS SERVICES

REQUEST FOR CERTIFICATION

This form must be completed and returned to the Financial Aid Office 30 days prior to the beginning of EACH semester.  Forms returned late may cause a delay in the payment of benefits.  Inaccurate or incomplete information may cause a termination of your benefits.

Name___________________________________________________________________

Telephone_______________________________________________________________

Social Security Number_________________ VA File Number_____________________

Mailing Address__________________________________________________________

E-mail Address___________________________________________________________

VA Benefits Chapter (Check One):

_____ Chapter 30 (Montgomery GI Bill)

_____ Chapter 31 (Vocational Rehabilitation)

_____ Chapter 32 (Veterans Educational Assistance Program-VEAP)

_____ Chapter 35 (Survivors & Dependents)

_____ Chapter 1606 (Montgomery GI Bill – Selected Reserve or National Guard)

_____ Chapter 1607 (Reserve Educational Assistance Program-REAP)

Are you currently on Active Duty? _____ Yes _____ No

Semester For Which Benefits Are Being Requested (Check One):

_____ Fall                    _____ Spring               _____ Summer

Program of Study at YCCC (Degree/Major)__________________________________

Please list below the courses in which you are enrolled and are requesting certification for VA Educational Benefits:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

______________________________________________    ________________________

Student’s Signature                                                                   Date