GI Bill® Certification Worksheet

GI Bill® Certification Worksheet

“GI Bill® is a registered trademark of the United States Department of Veterans Affairs (VA)
Name*

First NameLast Name
RIC Student ID Number
Current Program of Study / Major
Phone Number

Area CodePhone Number
Email*
example@example.com
VA Education Benefit: Please check your current chapter status

Chapter 30 (Montgomery GI Bill®)Chapter 31 (Veteran Readiness & Employment)Chapter 33 (Post 9/11)Chapter 35 (Dependents DEA) *May need service member's informationChapter 1606 (MGIB Select Reserve)
Chapter 31 VR&E Case Manager Name
Are You the Veteran's

SpouseDependent
Using a STAP Waiver

YesNo
Using Disabled American Veteran (DAV) Waiver

YesNo
Please Indicate the Semester You Need Certification

FallSpringWinterSummer ISummer II
Total Registered Credits
Are You Completing a Clinical or Internship Placement This Semester?

YesNo
Location
Is It Your Intent to Waive RIC Accident and Health Insurance?

YesNo
* It is the student's responsibility to waive health insurance from their account. Indicating "Yes" on this form does not result in your insurance being waived.
Initials

Clear
Important info regarding your VA payment, please check that you read and understand the information
- Notify the Certifying Official immediately if you change your schedule, drop a class, withdraw from a class, etc. Also, it is your responsibility to provide verification of Mitigating Circumstances.
SIGNATURE Required: I attest the information above is true and accurate. I understand that I am responsible for any unpaid balance that the VA does not cover. This is a RIC form and must be completed every semester.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: