NEW STUDENT DATA FORM for VA Education Benefits
ALLEN COMMUNITY COLLEGE

1801 Cottonwood Iola KS 66749

Phone: 620-365-5116 ext 6291

Fax 620-365-7403

ACC ID		NAME
ADDRESS		CITY STATE ZIP
SSN		PHONE #
I have used my benefits before:NO YES		-- If yes: List where:

Do you currently owe an overpayment to the VA?no yes

I plan to use the following benefit - mark only ONE:

CHPT 30 M Montgomery GI Bill (MGIB)-contributed $

CHPT 33 Post 9/11 GI Bill available starting Aug. 2009)

CHPT 1606 MGIB for Select Reserve/National Guard

CHPT 1606 MGIB for Select Reserve/National Guard w/kicker

CHPT 1607 REAP Reserve/Guard deployed 90 days on or after 9/11/01

Veterans Retraining Assistance Program (VRAP)

CHPT 31 VA Vocational Rehabilitation

CHPT 35 Dependent/Survivor Education Assistance -- VA File #

***MY EXPECTED MONTHLY VETERANS BENEFIT PAY RATE FOR FULL TIME ENROLLMENT IS $***

I plan to enroll at ACC in the:
I request to be certified to the VA as a:

ACC DEGREE/CERTIFICATE STUDENT - PLEASE LIST PROGRAM:

GUEST STUDENT-PLEASE LIST PARENT SCHOOL:
To be certified, GUEST STUDENTS must request "PARENT SCHOOL LETTER" be sent to ACC Veterans Services Office.

Changes to your course schedule OR enrollment in classes outside your current compliance agreement, repeating successfully completed classes, or enrolling in short-term classes, may result in the VA determining an overpayment in your benefit - all overpayments are the responsibility of the benefit recipient.
You must attend class and make satisfactory academic progress as defined in the ACC Student Handbook.
You must submit a Veterans Recertification Worksheet to the ACC Veteran Services office to have subsequent semester enrollments certified to the VA.
Prior credit from all previous colleges, as well as your DD214, must be evaluated and credited toward your degree/certificate requirements.
If you change your ACC degree/certificate intent, you must notify the ACC Veteran Services office and complete a new Compliance Agreement.
The ACC VA Office corresponds via the ACC student email system. It is your responsibility to check your ACC student email account.

By submitting this form I state that I have provided accurate information, have read and understand the above statements, and agree to comply with all VA guidelines.