California College Fee Waiver

CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS

COLLEGE FEE WAIVER PROGRAM FOR VETERAN DEPENDENTS
I. Student Information
Student's Name*

First NameMiddle InitialLast Name
Student's Social Security Number*
Student's Date of Birth*

MonthDayYear
Student's Date of Birth*

MonthDayYear
Date
Student's Marital Status*

MarriedSingle
Student's Address*

Street Address

Street Address Line 2

CityState

ZipCountry
Student's Telephone Number*
Please enter a valid phone number.
Student's E-mail*
example@example.com
Student's relationship to veteran in Section III below:*

Adopted ChildStepchildSpouseSurviving SpouseBiological Child
Have you applied for this benefit before?*

YesNo
VA EDUCATIONAL BENEFITS UNDER CHAPTER 35
Are you ELIGIBLE to receive Chapter 35 Benefits?*

YesNo
Are you CURRENTLY receiving Chapter 35 Benefits?*

YesNo
Simultaneous receipt of benefits under CFW Plan A and VA Chapter 35 benefits is prohibited. However, a dependent may still be eligible under Plan B, pending the provision of income verification. Children are the only dependents eligible under Plan B and there is no prohibition against receiving concurrent VA Chapter 35 benefits. The child's annual income, which includes the child's adjusted gross income, plus the value of support provided by a parent, may not exceed the annual income limit. The current academic year entitlement is based upon the student's previous calendar year's annual income.
ADJUSTED GROSS INCOME (AGI) of student from last year (January 1st through December 31st)
ANNUAL VALUE OF ANY SUPPORT RECEIVED FROM A PARENT
Plan B Dependents: In cases where the DVS 40 application reports $0 AGI & $0 Value of Support, a certified statement must be completed which explains how the student affords to attend college and supports themselves.
*NOTE: Examples of support include, but are not limited to: college housing, transportation, books, school supplies, medical care etc. Under plan B, the total amount of the child’s income and value of support, as listed above, cannot exceed the “national poverty level” as determined by the U.S. Census Bureau and published by the California Department of Veterans Affairs. Refer to “Who May Apply Under Plan B” on the next page for required statements, if you entered zero on AGI and Annual Value of Support.
II. SCHOOL INFORMATION
CALIFORNIA COLLEGE or UNIVERSITY you are attending or plan to attend*
ACADEMIC YEAR for which you are requesting waiver of tuition/fees*
III. VETERAN'S INFORMATION
Veteran's Last Name (Served Under if Currently Different):*

First NameMiddle InitialLast Name
Veteran's Social Security Number or VA Claims Number:*
Veteran's Date of Birth*

MonthDayYear
Veteran's Date of Birth*

MonthDayYear
Date
Date of Death (if applicable.) Please provide copy of death certificate if not already on file.

MonthDayYear
Date of Death (if applicable)

MonthDayYear
Date
Branch of Military Service:*
Begin Date of Active Duty Military Service*

MonthDayYear
Begin Date of Active Duty Military Service

MonthDayYear
Date
End Date of Active Duty Military Service*

MonthDayYear
End Date of Active Duty Military Service

MonthDayYear
Date
Veteran's Address

Street Address

Street Address Line 2

CityState

Zip
Veteran's Phone Number*
Please enter a valid phone number.
Veteran's Email*
example@example.com
Is the veteran alive or deceased?*

AliveDeceased
If the veteran is alive, what is the veteran's current "service-connected" disability rating adjudicated by either the US Military or the US Department of Veterans Affairs?
If the veteran is deceased, was the death "service-connected", or did the veteran have a "service-connected" disability at the time of his or her death?

YesNo
I hereby certify under penalties of perjury that the information contained in this application and supporting documents is given for the purpose of obtaining educational benefits and is true, correct, and complete. I authorize the California Department of Veterans Affairs (CalVet) employees, officers, and designees to verify these documents. I hereby authorize the U.S. Department of Veterans Affairs, Department of Defense, Internal Revenue Service, and the Franchise Tax Board, to release information regarding my service-connected disability rating and/or income to CalVet with the understanding that the department will keep such information confidential. I hereby authorize the release of my CalVet College Fee Waiver Program for Veterans Dependents award letter to the College or University for which I am applying. I understand that educational benefits may be denied or found to be my responsibility to repay if any information is found to be false, intentionally incomplete, or misleading.
Is Veteran able to sign?*

YesNo
Signature of Veteran*

Clear
Use your mouse, touchpad, or touchscreen in the area above to provide your signature.
Veteran Signature Date*

MonthDayYear
Veteran Signature Date*

MonthDayYear
Date
(If veteran is unable to sign, parent/veteran spouse must complete and attach a VSD-021)

Cancelof
Signature of Student*

Clear
Use your mouse, touchpad, or touchscreen in the area above to provide your signature.
Student Signature Date*

MonthDayYear
Student Signature Date*

MonthDayYear
Date
Should be Empty:

CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS

I. Student Information

VA EDUCATIONAL BENEFITS UNDER CHAPTER 35

II. SCHOOL INFORMATION

III. VETERAN'S INFORMATION