Veteran Services Benefit Certification Form All new students must complete and return the VA Responsibility Form before your enrollment can be certified. Asterisk indicates required field. ( * ) Personal Information First Name * Last Name * Phone * Ext. Home Cell Business Other Student ID * Social Security (Format: ###-##-####) Address Address (line 1) * Address (line 2) P.O. Apt. City * State * AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip * Chapter Select your Chapter * Chapter 30 Montgomery G.I. Bill / VRAP Are you on active duty? Yes No Chapter 33 Post 9/11 Are you receiving Federal Tuition Assistance? Yes No Chapter 35 Survivor's and Dependent Assistance Program VA File Number Chapter 1606 Selected Reserve Chapter 1607 Reserve Educational Assistance Program (REAP) Degree Plan Degree * If this is a change in degree from your previous semester, please fill out a Change of Program/Place of Training Form and return it to your VA Certifying Official in order for your enrollment to be certified. Classes For which semester are you requesting your enrollment to be certified with the VA? Semester * Please Select... Fall Winter Spring/Summer Year * I am interested in the Student Veterans of America group at Jackson Community College Confirmation * I have read, understand, and submitted the VA Responsibility Form. * I understand that all correspondence will be sent to my JCC Email account. * I confirm that all the information submitted here is accurate.