Student Records-VA Request for Certification

Student Records Office

VA Request for Certification
Print the form, complete it, and send to the Office of Student Records (800 Lakeshore Drive, Birmingham, AL 35229-7030), or fax it to (205) 726-2908. PLEASE TYPE OR PRINT CLEARLY.
Name: _________________________________________________________ Last First Middle Banner SUid or SSN: ___________________ VA File Number: _______________
Mailing Address: _________________________________________________ ______________________________________________________________ City: ____________________________ State: __________ Zip: ___________ 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 Student Records Office.)
VA Benefit:	Please certify me for the following terms:
____ Chapter 30 (MGIB - ACTIVE DUTY) ____ Chapter 31 (VOC REHAB) ____ Chapter 32 (VEAP) ____ Chapter 35 (SURVIVORS/DEPENDENTS) ____ Chapter 1606 (MGIB - NATIONAL GUARD _____ RESERVES _____)	____ Fall 2007 ____ Jan Term 2008 ____ Spring 2008 ____ Summer 1st Half 2008 ____ Summer 2nd Half 2008
STATEMENT OF UNDERSTANDING
I fully understand that I must report any changes to the VA Certifying Official 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: ____________

Page maintained by Jane Leask, Assistant Registrar (Certifications, Publications, & Programming), jeleask@samford.edu.
Last update: 7/27/07 9:10 AM
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