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This form must be completed in its entirety each term you register for classes before the School Certifying Official can submit your GI Bill benefits certification to the Veterans Administration (VA). If you have any questions, please contact the Veterans Services Specialist at 937-328-6462.













Note: Failure to disclose scholarships and/or tuition assistance can result in an over payment or loss of benefits.

I acknowledge that only courses required for my declared Clark State degree program(s) may be certified for benefits with the VA. My earned benefits will be based on the credit hours taken, actual dates of enrollment and my attendance in the course(s) as determined by the VA.

I further acknowledge that if I fail to immediately notify the School Certifying Official when my schedule changes, I withdraw from a class and/or I stop attending a class, I may incur a debt with the VA for unearned benefits and/or with Clark State for unpaid tuition and fees.