Veterans Resource Coordinator
Phone: (605) 642-6415
Fax: (605) 642-6095
1200 University Street, Unit 9518
Spearfish, South Dakota 57799-9518
2015 – 2016 Military / VA Benefit Information Sheet
Name ______________________________________________________ Phone#________________________________
VA File # ______________________________________________________ Student ID#__________________________
Permanent Mailing Address: __________________________________________________________________________
Non-BHSU email __________________________________ Branch of Service ___________________________________
(Primary correspondence will be sent to BHSU student email account)
Major (BA, BS, CERT) ____________________________Minor ________________Expected Graduation (MM/YY) _______
Status (Check all that apply)
Veteran
Active Duty
Where will you attend classes?
Spearfish Campus
Guard/Reserve
UC – Rapid City
Dependent/Spouse
Online/D2L
Which GI Bill do you use? -------------------------------------Follow-Up Questions, per chapter:
___Chapter 33, (Post 9/11, Fry, ToE) ---------------------- What is your % of Eligibility? _________ Are you a resident of SD? (Y/N) ____
___Chapter 30, (MGIB-Active)
___Chapter 1606, (MGIB-SR) ---------------------------------Which are you currently serving in? ___Guard ___Reserve
___Chapter 1607, (REAP) --------------------------------------Which are you currently serving in? ___Guard ___Reserve
___Chapter 35, (DEA) -------------------------------------------Veteran’s Claim/File# _________________
___Chapter 31, (VocRehab) -----------------------------------Contact your counselor. They must send submit a VA FORM 28-1905
___Other: (MYCAA, Free Tuition, etc.)---------------------What other benefits do you use? _________________________
MILITARY TUITION REDUCTION PROGRAMS
SD NG Soldiers & Airmen: Have you completed a SD NG Form 56 at your unit? (Y/N) ____ If no, contact your unit.
FOR ALL OTHER CURRENT SERVICE MEMBERS ATTENDING UCs: Have you completed SDBOR MILVET application? (Y/N) ____
ALL CURRENT SERVICE MEMBERS: Do you use Military Federal Tuition Assistance (FTA)? (Y/N)_____ If yes, submit proof of FTA approval.
Please list any other Tuition Assistance programs or Scholarships that you anticipate receiving: __________________________
Enrollment at Black Hills State University
Input expect number of credits per semester. Enter “0” or “NO” if you don’t want to use benefits for a semester.
Summer 2015 Expected Credits: _______
Are you interested in VA Work Study? _____
Fall 2015
Expected Credits: _______
Will you take classes at other schools*? ______*
Spring 2016
Expected Credits: _______
*If yes, you must notify our office each term!
-You must apply at www.benefits.va.gov/gibill in order to first start your benefits – that is a one-time application.
-This Info Sheet gives BHSU permission to certify your enrollment – this form is updated annually.
-If you have used benefits before at a different school, fill out a VA Form 22-1995 (or Form 22-5495 for Ch. 35) before your
benefits can be processed – this can be completed online and submitted the VA.
I hereby acknowledge that I must notify Veterans’ Services of all courses I take that do not satisfy a requirement in my degree
program.VA will not pay for these classes (extra electives, repeating a passed course, etc.). If I drop, add, or withdrawal from a
class I must inform Vet’s office to avoid any overpayments or non-payments. Any debts that are created are my responsibility to
repay. All benefits, other than Tuition & Fees, will be paid directly to me. Reminder: CH1606, 1607, and 30 must verify their
monthly enrollment on WAVE every month. This info sheet expires May2015. I have read and understand the above
information and have received a copy of the Student Counseling Form:
Signature_________________________________________Date_______________
Return to Veteran’s Service Office, Student Success Center, Woodburn 135. Once submitted by the certifying official to the VA, first time education
benefits will be processed in 6-12 weeks, recurring benefits may be processed sooner. You will get an automated email from the VA when your
credits have been submitted. VA: 888-442-4551. VA Fax: 314-552-9741
OFFICE USE ONLY: Is student coded? _________ Is Cert Completed? SP14?___ SU14? ___ FA14?____ SP15?____
Effective Date: 1 JAN 2015