California College Fee Waiver

Student's Name*

First NameMiddle InitialLast Name

Student's Social Security Number*

Student's Date of Birth*

MonthDayYear

Student's Date of Birth*

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:*

Have you applied for this benefit before?*

YesNo

Are you ELIGIBLE to receive Chapter 35 Benefits?*

YesNo

Are you CURRENTLY receiving Chapter 35 Benefits?*

YesNo

ADJUSTED GROSS INCOME (AGI) of student from last year (January 1st through December 31st)

ANNUAL VALUE OF ANY SUPPORT RECEIVED FROM A PARENT

*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.

CALIFORNIA COLLEGE or UNIVERSITY you are attending or plan to attend*

ACADEMIC YEAR for which you are requesting waiver of tuition/fees*

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*

Date

Date of Death (if applicable)

MonthDayYear

Date of Death (if applicable)

Date

Branch of Military Service:*

Begin Date of Active Duty Military Service*

MonthDayYear

Begin Date of Active Duty Military Service

Date

End Date of Active Duty Military Service*

MonthDayYear

End Date of Active Duty Military Service

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*

Use your mouse, touchpad, or touchscreen in the area above to provide your signature.

Veteran Signature Date*

MonthDayYear

Veteran Signature Date*

Date

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

Signature of Student*

Use your mouse, touchpad, or touchscreen in the area above to provide your signature.

Student Signature Date*

MonthDayYear

Student Signature Date*

Date

CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS

I. Student Information

VA EDUCATIONAL BENEFITS UNDER CHAPTER 35

II. SCHOOL INFORMATION

III. VETERAN'S INFORMATION