Da 2171 Form PDF Details

The DA Form 2171, crucial within the Army Continuing Education System, embodies the military's commitment to supporting the educational aspirations of its service members. Mandated by authoritative legislation under Title 10 USC 2007 and 2005, this document facilitates a structured process for requesting tuition assistance, thereby reinforcing the principle that furthering education enhances both personal and professional development. The primary purpose of this form is to document the courses for which a service member is receiving tuition assistance, ensuring accountability and proper use of government resources. It emphasizes the significance of successful course completion, stipulating that service members must reimburse the tuition assistance received if they fail to complete the courses due to controllable reasons. Moreover, it outlines the requirement for service members to obtain authorization on a course-by-course basis, and not through any additional agreements with educational institutions. This ensures a clear understanding that commitments are strictly between the individual service member and the Army, thereby safeguarding both parties' interests. The form also acts as a record for courses in progress, assisting in the recoupment of funds, if necessary. DA Form 2171 requires detailed input from the applicant, including personal identification, enrollment information, course relevance, and financial details, culminating in approvals from unit commanders and education officers, thereby streamlining the process of granting tuition assistance efficiently and effectively.

QuestionAnswer
Form NameDa 2171 Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesfc form 2171 pdf, ETS, fc form 2171, da form 2171

Form Preview Example

REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM

For use of this form, see AR 621-5; the proponent agency is DCSPER

CONTROL NUMBER

 

DATA REQUIRED BY THE PRIVACY ACT OF 1974

 

 

AUTHORITY

Title 10 USC 2007; Title 10 USC 2005

PRINCIPAL PURPOSE(S)

Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who,

 

due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse

 

the Army an amount equal to the tuition assistance received.

ROUTINE USES

Used as a record of courses in progress for which the service member is receiving tuition assistance.

 

Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for

 

reasons within his or her control.

DISCLOSURE

Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a

 

service member who fails to complete courses for reasons within his or her control.

APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN

1. APPLICANT'S NAME (Last, First, MI)

2.SSN

3.ETS

4.MOS

5.ORGANIZATION AND LOCATION OF ASSIGNMENT

6A. NAME OF SCHOOL

6B. ADDRESS OF SCHOOL (Include ZIP Code)

6C. LOCATION OF CLASS

6D. PURPOSE (Formally Declared Goal)

7.Course Data

DEPARTMENT AND COURSE NUMBER A

TITLE OF COURSES

B

 

 

NUMBER OF

DAYS OF

HOURS OF

SEMESTER OR

WEEK

MEETING

QUARTER

 

 

HOURS

C

D

E

 

 

 

CREDIT

HOUR COST

F

COURSE COST LESS FEES AND BOOKS

G

AMOUNT

PAID

H

8A. COURSE BEGINS

8B. COURSE ENDS

9.COST TO GOV'T

10.I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO.

A.SIGNATURE OF APPLICANT

B.OFFICE TELEPHONE NUMBER

C.DATE

11.Applicant's Unit Commander or Authorized Representative

Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2;

and anticipated duties will permit class attendance.

A.TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE

B.SIGNATURE

C.DATE

12.Tuition Assistance in the Amount Indicated in Item 9 Above is Approved

A.TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER

B.SIGNATURE

C.DATE

13.Fiscal

A.

CONTRACT NUMBER

B.

CHARGEABLE TO ORDER NUMBER

 

 

 

 

C.

ACCOUNTING CLASSIFICATION

D.

INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO

 

 

 

 

By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade

reports within 30 days of course completion.

DA FORM 2171, APR 89

Copy 1 - Institution

USAPPC V1.00

REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM

For use of this form, see AR 621-5; the proponent agency is DCSPER

CONTROL NUMBER

 

DATA REQUIRED BY THE PRIVACY ACT OF 1974

 

 

AUTHORITY

Title 10 USC 2007; Title 10 USC 2005

PRINCIPAL PURPOSE(S)

Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who,

 

due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse

 

the Army an amount equal to the tuition assistance received.

ROUTINE USES

Used as a record of courses in progress for which the service member is receiving tuition assistance.

 

Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for

 

reasons within his or her control.

DISCLOSURE

Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a

 

service member who fails to complete courses for reasons within his or her control.

APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN

1. APPLICANT'S NAME (Last, First, MI)

2.SSN

3.ETS

4.MOS

5.ORGANIZATION AND LOCATION OF ASSIGNMENT

6A. NAME OF SCHOOL

6B. ADDRESS OF SCHOOL (Include ZIP Code)

6C. LOCATION OF CLASS

6D. PURPOSE (Formally Declared Goal)

7.Course Data

DEPARTMENT AND COURSE NUMBER A

TITLE OF COURSES

B

 

 

NUMBER OF

DAYS OF

HOURS OF

SEMESTER OR

WEEK

MEETING

QUARTER

 

 

HOURS

C

D

E

 

 

 

CREDIT

HOUR COST

F

COURSE COST LESS FEES AND BOOKS

G

AMOUNT

PAID

H

8A. COURSE BEGINS

8B. COURSE ENDS

9.COST TO GOV'T

10.I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO.

A.SIGNATURE OF APPLICANT

B.OFFICE TELEPHONE NUMBER

C.DATE

11.Applicant's Unit Commander or Authorized Representative

Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2;

and anticipated duties will permit class attendance.

A.TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE

B.SIGNATURE

C.DATE

12.Tuition Assistance in the Amount Indicated in Item 9 Above is Approved

A.TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER

B.SIGNATURE

C.DATE

13.Fiscal

A.

CONTRACT NUMBER

B.

CHARGEABLE TO ORDER NUMBER

 

 

 

 

C.

ACCOUNTING CLASSIFICATION

D.

INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO

 

 

 

 

By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade

reports within 30 days of course completion.

DA FORM 2171, APR 89

Copy 2 - Commercial Accounts, Finance and Accounting Office (F&AO)

USAPPC V1.00

REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM

For use of this form, see AR 621-5; the proponent agency is DCSPER

CONTROL NUMBER

 

DATA REQUIRED BY THE PRIVACY ACT OF 1974

 

 

AUTHORITY

Title 10 USC 2007; Title 10 USC 2005

PRINCIPAL PURPOSE(S)

Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who,

 

due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse

 

the Army an amount equal to the tuition assistance received.

ROUTINE USES

Used as a record of courses in progress for which the service member is receiving tuition assistance.

 

Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for

 

reasons within his or her control.

DISCLOSURE

Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a

 

service member who fails to complete courses for reasons within his or her control.

APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN

1. APPLICANT'S NAME (Last, First, MI)

2.SSN

3.ETS

4.MOS

5.ORGANIZATION AND LOCATION OF ASSIGNMENT

6A. NAME OF SCHOOL

6B. ADDRESS OF SCHOOL (Include ZIP Code)

6C. LOCATION OF CLASS

6D. PURPOSE (Formally Declared Goal)

7.Course Data

DEPARTMENT AND COURSE NUMBER A

TITLE OF COURSES

B

 

 

NUMBER OF

DAYS OF

HOURS OF

SEMESTER OR

WEEK

MEETING

QUARTER

 

 

HOURS

C

D

E

 

 

 

CREDIT

HOUR COST

F

COURSE COST LESS FEES AND BOOKS

G

AMOUNT

PAID

H

8A. COURSE BEGINS

8B. COURSE ENDS

9.COST TO GOV'T

10.I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO.

A.SIGNATURE OF APPLICANT

B.OFFICE TELEPHONE NUMBER

C.DATE

11.Applicant's Unit Commander or Authorized Representative

Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2;

and anticipated duties will permit class attendance.

A.TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE

B.SIGNATURE

C.DATE

12.Tuition Assistance in the Amount Indicated in Item 9 Above is Approved

A.TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER

B.SIGNATURE

C.DATE

13.Fiscal

A.

CONTRACT NUMBER

B.

CHARGEABLE TO ORDER NUMBER

 

 

 

 

C.

ACCOUNTING CLASSIFICATION

D.

INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO

 

 

 

 

By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade

reports within 30 days of course completion.

DA FORM 2171, APR 89

Copy 3 - Accounting Division Accounts Maintenance Activity (F&AO)

USAPPC V1.00

REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM

For use of this form, see AR 621-5; the proponent agency is DCSPER

CONTROL NUMBER

 

DATA REQUIRED BY THE PRIVACY ACT OF 1974

 

 

AUTHORITY

Title 10 USC 2007; Title 10 USC 2005

PRINCIPAL PURPOSE(S)

Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who,

 

due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse

 

the Army an amount equal to the tuition assistance received.

ROUTINE USES

Used as a record of courses in progress for which the service member is receiving tuition assistance.

 

Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for

 

reasons within his or her control.

DISCLOSURE

Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a

 

service member who fails to complete courses for reasons within his or her control.

APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN

1. APPLICANT'S NAME (Last, First, MI)

2.SSN

3.ETS

4.MOS

5.ORGANIZATION AND LOCATION OF ASSIGNMENT

6A. NAME OF SCHOOL

6B. ADDRESS OF SCHOOL (Include ZIP Code)

6C. LOCATION OF CLASS

6D. PURPOSE (Formally Declared Goal)

7.Course Data

DEPARTMENT AND COURSE NUMBER A

TITLE OF COURSES

B

 

 

NUMBER OF

DAYS OF

HOURS OF

SEMESTER OR

WEEK

MEETING

QUARTER

 

 

HOURS

C

D

E

 

 

 

CREDIT

HOUR COST

F

COURSE COST LESS FEES AND BOOKS

G

AMOUNT

PAID

H

8A. COURSE BEGINS

8B. COURSE ENDS

9.COST TO GOV'T

10.I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO.

A.SIGNATURE OF APPLICANT

B.OFFICE TELEPHONE NUMBER

C.DATE

11.Applicant's Unit Commander or Authorized Representative

Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2;

and anticipated duties will permit class attendance.

A.TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE

B.SIGNATURE

C.DATE

12.Tuition Assistance in the Amount Indicated in Item 9 Above is Approved

A.TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER

B.SIGNATURE

C.DATE

13.Fiscal

A.

CONTRACT NUMBER

B.

CHARGEABLE TO ORDER NUMBER

 

 

 

 

C.

ACCOUNTING CLASSIFICATION

D.

INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO

 

 

 

 

By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade

reports within 30 days of course completion.

DA FORM 2171, APR 89

Copy 4 - AEC Suspense File

USAPPC V1.00

REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM

For use of this form, see AR 621-5; the proponent agency is DCSPER

CONTROL NUMBER

 

DATA REQUIRED BY THE PRIVACY ACT OF 1974

 

 

AUTHORITY

Title 10 USC 2007; Title 10 USC 2005

PRINCIPAL PURPOSE(S)

Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who,

 

due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse

 

the Army an amount equal to the tuition assistance received.

ROUTINE USES

Used as a record of courses in progress for which the service member is receiving tuition assistance.

 

Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for

 

reasons within his or her control.

DISCLOSURE

Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a

 

service member who fails to complete courses for reasons within his or her control.

APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN

1. APPLICANT'S NAME (Last, First, MI)

2.SSN

3.ETS

4.MOS

5.ORGANIZATION AND LOCATION OF ASSIGNMENT

6A. NAME OF SCHOOL

6B. ADDRESS OF SCHOOL (Include ZIP Code)

6C. LOCATION OF CLASS

6D. PURPOSE (Formally Declared Goal)

7.Course Data

DEPARTMENT AND COURSE NUMBER A

TITLE OF COURSES

B

 

 

NUMBER OF

DAYS OF

HOURS OF

SEMESTER OR

WEEK

MEETING

QUARTER

 

 

HOURS

C

D

E

 

 

 

CREDIT

HOUR COST

F

COURSE COST LESS FEES AND BOOKS

G

AMOUNT

PAID

H

8A. COURSE BEGINS

8B. COURSE ENDS

9.COST TO GOV'T

10.I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO.

A.SIGNATURE OF APPLICANT

B.OFFICE TELEPHONE NUMBER

C.DATE

11.Applicant's Unit Commander or Authorized Representative

Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2;

and anticipated duties will permit class attendance.

A.TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE

B.SIGNATURE

C.DATE

12.Tuition Assistance in the Amount Indicated in Item 9 Above is Approved

A.TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER

B.SIGNATURE

C.DATE

13.Fiscal

A.

CONTRACT NUMBER

B.

CHARGEABLE TO ORDER NUMBER

 

 

 

 

C.

ACCOUNTING CLASSIFICATION

D.

INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO

 

 

 

 

By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade

reports within 30 days of course completion.

DA FORM 2171, APR 89

Copy 5 - DA Form 669 or soldier

USAPPC V1.00

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