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there is no application deadline, but early application is encouraged. please return the completed application to: missouri department of
higher education, attn: vietnam veterans survivors grant program, p.o. box 1469, jefferson city, mo 65102-1469.
i am:
an initial applicant who has never before completed this application. complete sections i, ii, iii, and iv. section v must be completed
by a missouri state veterans administration official. section vi must be completed by a financial aid officer at the institution where you
plan to enroll or are currently enrolled.
a prior recipient applying for a renewal award. complete sections i, ii, and iv. section vi must be completed by a financial aid officer
at the institution where you plan to enroll or are currently enrolled.
a transfer student planning to enroll or currently enrolled in a different school than the one listed on my most recent application for the
current academic year. complete sections i, ii and iv. section vi must be completed by a financial aid officer at the institution where
you plan to enroll or are currently enrolled.
privacy act notice. Your social security number is being requested on this form pursuant to the authority of section 173.236, rsmo,
subject to the provisions of section 7 of the privacy act of 1974, pub. l. 93-579. You do not have to disclose your social security number.
You will not be denied any right, benefit, or privilege provided by law in regard to the vietnam veterans survivors grant program if you
refuse to disclose your social security number on the application. if you do disclose your social security number, that number will be used
to verify your identity, and as an identifying number in order to record necessary data accurately. as an identifier, the social security number
is used in such program activities as determining program eligibility, and certifying school attendance and student status.
1. last name
first name
mi
3. date of birth (mm/dd/YYYY) (if You are the veterans dependent child You must be less than 25 Years old.)
6. e-mail address
7. name of the college or universitY where You plan to enroll or are currentlY enrolled
8. for which semester or semesters are You requesting aid? You maY onlY request aid for one academic Year per application
(YYYY)
certificate
associate degree
baccalaureate degree
2nd baccalaureate degree
section iii - veteran information (required for all initial applicants only.)
11a. was the veteran a permanent missouri resident when first entering
11a. militarY service?
Yes
no
masters degree
doctorate
11b. was the veteran a permanent missouri resident at the time of death?
Yes
no
i was the veterans dependent child (natural child, adopted child, or stepchild) at the time of death.
i was the veterans spouse at the time of death. (spousal eligibility expires on the fifth anniversary after the veterans death.)
i certify the information provided in sections i, ii, and iii is true, complete, and correct to the best of my knowledge. as to any award made
to me as the result of this application, i hereby authorize the school to pay to the mdhe any refund which may be due to me up to the
amount of this award if i withdraw or drop below full time status during the schools refund period. i certify that the proceeds of any award
made as a result of this application will be used for educational purposes at the school and for the enrollment period listed on this
application.
13b. date
17. did the veteran named in section iii above serve in vietnam or the war zone in southeast asia between 1961 and 1972?
19. has a veterans administration medical authoritY certified the death of the vietnam veteran was contributed to or caused bY exposure to toxic chemicals
during the vietnam conflict?
Yes
no
veterans administration official completing this application
i certify the information provided in section v is true, complete, and correct to the best of my knowledge, and the veterans service qualifies the
applicant for a vietnam veterans survivors grant award.
22. address
state
zip code
25. period of enrollment for which the grant is being requested (both fall semester and spring semester maY be selected.)
fall semester
spring semester
(mm/dd/YYYY)
(mm/dd/YYYY)
(mm/dd/YYYY)
(mm/dd/YYYY)
26. tuition for the period of enrollment. tuition amounts must reflect the amount of tuition and/or incidental fee charged a full-time, missouri undergraduate
resident for twelve (12) credit hours for the period of enrollment.
Institution
tuition amount
fall
spring
fall
spring
Yes
no
Yes
no
31. is the applicant enrolled full time or intending to enroll full time?
Yes
no
Yes
no
30. has the applicant completed a total of at least 150 semester credit hours?
Yes
no
32. is the applicant making satisfactorY academic progress as defined bY the institution for federal title iv aid purposes?
Yes
no
i certify the information provided in section vi is true, complete, and correct to the best of my knowledge. i also certify the applicant named in
section i is accepted for enrollment or intends to enroll for the period of enrollment indicated in this section, is in good standing as a full-time
student, is making satisfactory academic progress at the school, and has been determined to be eligible for the vietnam veterans survivors
grant program.
mo 555-0198 (2-14)
34d. date