Semester
(Check one)
Fall 2015
Winter
Spring 2016
Summer 2016
OFFICE USE ONLY
DATE
RECEIVED:__________
RECEIVED BY:__________
VA ENROLLMENT & BENEFITS AGREEMENT FORM
EACH OF THE FOLLOWING QUESTIONS ON PAGES 1-4 MUST BE ANSWERED AND INITIALED.
Last Name: _________________________________ First Name: _______________________________
Harford ID #: ________________________________ SSN#: ___________________________________
Address: _______________________________________________________________________________
Street
City
State
Zip Code
Is Your State of Residence Maryland? _____ If Not, List Your State of Residency: ______________________
Telephone Number: _____________________________ Alternate Number:__________________________
Please check all that apply:
_____
_____
_____
_____
_____
Chapter 30 – M GI Bill
Chapter 31 – Voc/Rehab
Chapter 33 – Post 9/11
Chapter 1606 – Reservist
Receiving a PELL Grant
_____
_____
_____
_____
_____
Chapter 1607 – R.E.A.P
Chapter 35 – Dependent Education Assistance
TA – Tuition Assistance
Other – List Program Name:___________________
Receiving a Scholarship: List Name of Scholarship
__________________________________________
Check ONE of the following:
_____
I am a NEW STUDENT and have NEVER USED my VA Educational Benefits
_____
I am a RETURNING STUDENT who has received VA Educational Benefits at THIIS SCHOOL in the past.
_______________Year previously attended
_____
I am a TRANSFER STUDENT. I used VA Educational Benefits at another College. List the names of all
previously attended colleges:
_____________________________________ _____________________________________
_____
_____________________________________
_____________________________________
_____________________________________
_____________________________________
I am a GUEST STUDENT who is taking courses at Harford concurrently with another College that is my
PARENT College. (ATTACH a Parent Letter from that institution when you submit this packet)
OFFICIAL College and Military Transcripts must be submitted to the Registration & Records Office to be evaluated
for transfer credit. All transcripts must be submitted for evaluation BEFORE THE END of your first semester.
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NAME:_____________________________________ HCC ID#:___________________ DATE:___________
Read each statement and initial indicating that you understand the statement. If you need clarification
before submitting the forms, please contact the Military & Veteran Services office at 443-412-2100 or by
email at vetsmilitary@harford.edu:
THE FOLLOWING STATEMENTS APPLY TO ALL CHAPTERS
WHILE RECEIVING VA EDUCATION BENEFITS AT HARFORD COMMUNITY COLLEGE, I UNDERSTAND THAT:
_____ I must register for classes at Harford before submitting this VA Enrollment Packet.
_____ I must submit a copy of the ‘Letter of Eligibility’ or a Notice of Basic Eligibility (N.O.B.E.) that I received from the VA
office outlining my educational benefits. (If you were certified for VA Educational benefits last semester, you are not
required to submit this document again, unless your benefits have changes)
_____
I must submit a copy of my DD214.
_____
I must complete the VA enrollment packet each semester that I request VA Educational Benefits
_____ I must submit copies of ALL official transcripts from the Military and previous colleges I have attended to the Registration
and Records Office, by the end of the first semester of my enrollment at Harford. I realize that I will not be certified for
subsequent semesters until all transcripts are evaluated.
_____ It may take two weeks or longer for my enrollment forms to be processed and the certification to be submitted to the VA
Regional Office. I know that this will depend on when I submit my Completed VA Enrollment Packet to the Certifying
Official.
_____ I am RESPONSIBLE FOR & MUST NOTIFY the Certifying Official IMMEDIATELY, if I make any changes to my class
schedule BEFORE or DURING the semester I am registered for. I AM AWARE THAT FAILURE TO NOTIFY THE CERTIFYING
OFFICIAL CAN RESULT IN ADJUSTMENT DELAYS, WHICH CAN CAUSE AN OVERPAYMENT/DEBT WITH THE VA.
_____ It is MY RESPONSIBILITY to notify the Certifying Official if I decide that I DO NOT want to receive VA Educational
benefits for any semester that I am enrolled in.
_____ It is my responsibility to contact the Certifying Official if I am reactivated during the semester, and should I have to
withdraw from classes. I also know that I will need to submit a copy of my orders.
_____ It is my responsibility to meet with a VA Academic advisor and select a degree plan at the beginning of my first semester
at Harford. I will not be certified for enrollment until I have selected a degree plan.
_____ I can ONLY be paid for courses which are required for the degree I am seeking at Harford. If I am enrolled in courses
outside of my degree plan, the Certifying Official will not certify me for those credits.
_____
I will not receive payment for courses which I have not successfully completed (‘D’ or better for most programs)
_____ The VA Regional office will be notified if I receive one of the following course grades and as a result of these grades I
may incur a debt with the Veterans Administration
F - Failure to meet course requirements
W - Course withdrawal without a grade (VA Certifying Official must be notified)
IIncomplete (VA Certifying Official must be notified of the date the course will be completed)
K - Audit – not for credit (VA Certifying Official must be notified)
_____ I can only be certified for courses that number below 100, if the Skills Assessment Test indicates that these courses are
required.
_____ Harford is not involved in the calculation of my VA educational benefit amount, other than certifying the correct number
of semester hours I am enrolled in each semester.
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NAME:_____________________________________ HCC ID#:___________________ DATE:___________
_____ I am responsible for payment of any portion of the tuition, fees, and books not covered my VA benefits.
_____ I have received information on alternative methods of tuition payment (attached to this packet is information on
alternative methods of payment. This information is for you to keep and should not be returned with your enrollment
forms)
_____ Twelve credits during the Spring and Fall semester is equivalent to full-time enrollment, and I must remain enrolled in 12
credits for the entire 15 weeks of the semester to maintain full-time status. I further know that the Summer & Winter
sessions are calculated by the VA Regional office and that they are based on a semester hour equivalency (website for
VA conversion tool: http://department-of-veterans-affairs.github.io/gi-bill-comparison-tool/)
_____ The Certifying Official has the authority to release information and documents to the Veterans Administration, as they
pertain to my educational benefits and academic progress at Harford.
_____ It is my responsibility to stay informed, through the Regional Veterans Administration Office, regarding specific
requirement for educational benefits. (website: www.va.gov)
THE FOLLOWING STATEMENT APPLIES TO CH 30, CH 1606, & 1607
_____ I must verify my enrollment on the last day of every month to the Department of Veteran Affairs in order to receive my
monthly benefit check. (Student can go online to www.gibill.va.gov and click the WAVE link, or they can call 1-877-8232378).
THE FOLLOWING STATEMENTS APPLY TO CH 30
_____
I am responsible for making the payment of my tuition and fees directly to Harford.
_____
I will be dropped from my classes if payment is not received by the tuition due date.
_____
My education benefits are sent directly to me by the Department of Veteran Affairs.
THE FOLLOWING STATEMENTS APPLY TO CH 33
_____ Tuition and fees are paid directly by the VA to Harford at the In-State rate only and that I will be responsible for any out
of state difference, and if I am not receiving 100% of the educational benefits I will be responsible for the remainder of
the tuition and fees.
.
_____ My book stipend is sent directly from the VA Regional office to me and that it may not arrive until after classes have
started, depending on when I registered and submit my forms to the Certifying Official.
_____ I must be enrolled in at least 7 credit hours, with at least one of those credits in a face-to-face format, for a 15 week
semester to receive Basic Allowance for Housing (BAH). Hybrid classes are considered online classes by the VA.
(website for VA conversion tool: http://department-of-veterans-affairs.github.io/gi-bill-comparison-tool/)
_____ In order for the Certifying Official to put a hold on my account so that I will not be dropped for non-payment, I must
submit my completed VA Enrollment Packed at least 7 days prior to the drop date.
THE FOLLOWING STATEMENT APPLIES TO CH 35
____________________ is my VA File Number (This number is required in order to process your certification. Your certification
CANNOT be processed without this number. Normally, this is the last four of your parent’s social security number.)
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I certify that I have read and understand the information contained in this Harford Community College’s VA
Enrollment & Benefits Agreement Packet. I further understand that pages 1-4 must be COMPLETED
ENTIRELY for my request for certification under the Veterans Affairs Educational Benefits program to be
considered by Harford. I realize that if I submit an incomplete packet that the entire Enrollment Packet will
be returned to me, and processing of my certification for educational benefits will not begin until I submit a
completed Enrollment Packet.
Print First and Last Name
Student Signature
Date
VA STUDENT FAILING GRADE POLICY
I (print your name here) ______________________________________________, understand and agree that if I
receive a failing (F) grade for one or more of my courses for any semester that I have been certified to receive
Educational benefits, I may be indebted to the Department of Veteran Affairs for the amount of benefits I received for
the course(s), depending on my last date of attendance. The VA Certifying School Official is required to report last
date of attendance for every course in which I made an ‘F’. If the Department of Veterans Affairs warrants an
overpayment based on my last date of attendance, I will receive a Notification of Debt from the Department of
Veteran Affairs and will be required to pay the amount owed on the notification. If my absence from classes resulted
in the failing grade and it was due to mitigating circumstances, it is MY RESPONSIBILITY to notify the VA Certifying
Official BEFORE the end of the semester regarding my situation.
I further understand that Harford Community College is in no way responsible for any debt owed to the Veteran
Affairs Office for any courses that I failed to complete successfully.
Student Signature
Date
VA COURSE WITHDRAWALS AND DROPS
I (print your name here) ___________________________________________ understand and agree that I must
report any course withdrawals and/or drops to the VA Certifying School Official. The VA Certifying College Official
will notify the VA Regional office of any changes to my enrollment and make the necessary enrollment adjustments
to my VA certification accordingly to my changes in enrollment.
Student Signature
Date
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Mitigating Circumstances for Veterans New VA Policy Begins November 15, 2015
The VA now requires that students using the Post 9/11 or Chapter 33 GI Bill Educational benefits to
provide documentation of mitigating circumstances when they withdraw from a course after the drop/add
period has ended and they receive a non-punitive grade. Mitigating circumstances are documented,
unanticipated and unavoidable events that interfere with the pursuit or completion of a course and result in
a student receiving a non-punitive grade.
Acceptable mitigating circumstances must be provided in order to pay benefits for the period of attendance
prior to the drop date. If they are not provided and accepted, any benefits paid from the beginning date of
the term will be considered an overpayment, and a debt may be established.
Mitigating circumstances may be claimed by submitting documented evidence when you withdraw or
otherwise incur an overpayment. Claims may be submitted on a VA Form 21-4138
(http://www.vba.va.gov/pubs/forms/vba-21-4138-are.pdf) with an explanation of the circumstances. The VA
decides whether to accept mitigating circumstance. The following are some general categories of
mitigating circumstances:





Course cancelled by the college
Serious illness of the veteran or dependent
Unanticipated call to active duty military service
Immediate family or financial obligations requiring a change in employment that precludes pursuit of
course
Serious illness or death in the eligible veteran's or dependent's immediate family
Examples of unacceptable mitigating circumstances include - but are not limited to:
 Withdrawal class(es) to avoid a failing grade
 Disliking an instructor
 Any courses attempted or a call to active duty that was anticipated before the term began
Print First and Last Name
___________________________________________________________
_______________________
Student Signature
Date
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