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Veteran Certification Request Form for Educational Benefits* *First semester students need to certify in person. *Students desiring advance payment must complete the certification process at MCC's Veterans Services in person. First Name: Last Name: Middle Initial: Email Address: Phone: (including area code) Last 4 Digits of SS#: VA Claim Number: (Chapters 31 and 35 only:) Are you currently on active duty? Yes No Note: If you are planning to move, please notify our office immediately - Failure to notify the VA could result in an iterruption of payments. This need to be completed in person. Current Mailing Address:(for VA Checks, Correspondence, and Forms) Street: City: State: Zip Code: Local Address: (If different from above) Street: City: State: Zip Code: Enrollment Status: Non-Degree Certificate Degree Note: If you make a change in your program you need to notify our office immediately - Failure to notify the VA could result in an iterruption of payments. This need to be completed in person. Current Degree Program: VA Educational Benefits: Montgomery G.I. Bill: Active Duty (Chapter 30) Selected Reserves (Chapter 1606) (VEAP) Veterans Educational Assistance Program (Chapter 32) (DEAP) Dependents' Educational Assistance Program (Chapter 35) Vocational Rehabilitation (Chapter 31) Have you ever used your benefits before? Yes No If Yes, list the name of the last school and the semester you received these benefits. How many credits are you taking? 12 or more 9 - 11 6 - 8 4 or 5 3 or fewer Current Class Schedule: (Include course, section number and the # of credit hours) ie. ENG 101-001(3cr)

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