Dma Form 189 E – Fill Out and Use This PDF

WISCONSIN NATIONAL GUARD TUITION GRANT APPLICATION

Application in compliance with: Privacy Act of 1974, E09397; WIARNG Regulation #621-7, WI ANG Regulation #53-0 and WI Statutes, Section 321.40. Completion of form is voluntary, however, lack thereof will prevent grant processing. Personal information will not be used for any other purpose.

STUDENT PORTION: THIS APPLICATION MUST BE RECEIVED AT THE DEPARTMENT OF MILITARY AFFAIRS (DMA) NO LATER THAN 60 DAYS AFTER EACH COMPLETION OF A COURSE OR TERM, WHICHEVER OCCURS FIRST. After completing all lines in the student portion, the applicant must submit this application to the appropriate College Registrar’s Office or Veterans’ Office for certification of the school portion. Submit an application even if a course(s) is incomplete. Reimbursement is based on 100% of the tuition charged at the student’s qualifying school or the maximum resident undergraduate tuition charged by the University of WI Madison, whichever is less. This grant will be suspended if the soldier/airman is AWOL or flagged & denied if the student is delinquent in child support or maintenance payments s. 49.854(2)(b), WI Stats. Direct questions to the DMA Tuition Grant Specialist at 608-242-3159.

Social Security Number: ____ ____ ____ - ____ ____ - ____ ____ ____ ____ Check Guard Membership: Army ____ Air _____

Print Name: __________________________ _______________ ______________________________ Check: Male ____ Female _____

FirstMiddleLast

Address where check should be sent: ___________________________________________ City: _________________________________

State: _____ Zip: ______________ Birthdate: __________ Academic Term Dates From: ______/_____/_____ To: ______/_____/_____

Month Day Year Month Day Year

School Name: ___________________________________________ # of credits anticipated this academic term ______________________

I certify that: (1) the above information is correct, (2) I do not have a Bachelor’s Degree, (3) I must achieve a minimum grade point average of 2.0 for each term, (4) I know that the application must be received by DMA within 60 days of the term end date & I will call 608-242-3159 prior to the 60 day deadline if I question that my application has reached DMA, (5) I am aware that if I do not satisfactorily fulfill my military obligations, DMA will pursue recoupment for the tuition grants awarded, (6) the school may release this information to DMA, (7) I cannot simultaneously apply for VetEd or theWI GI Bill, (8) to be reimbursed I must be an actively drilling WI Guard member, but not an officer, upon the completion of this term, (9) if I do not understand all form directions including the qualifying school list, I will call 608-242-3159 for assistance prior to college application. Find qualifying school list & applications at http://dma.wi.gov/dma/dma/education.asp .

Signature: ___________________________________ Date: ___________________ Telephone: ________________________________

SCHOOL PORTION: After classes are completed, the School’s Registrar or Veteran’s Representative certifies this form for the above

named student & term. The school keeps a copy & submits this application within 60 days of the term completion to: WI Department of Military Affairs, WIAR-PA-ED, PO Box 8111, Madison, WI, 53708-8111. Upon fulfillment of previously incomplete course(s), adjust the number of satisfactory credits & the tuition paid, then submit to DMA. Direct questions to the DMA Tuition Grant Specialist 608-242-3159.

School Name:___________________________________________________________USDOE Federal School Code:__________________

Beginning date of most recently completed term: ______/______/_____ Ending date of most recently completed term: ______/_____/_____

Month Day YearMonth Day Year

# of credits satisfactorily completed this term: ___________________________ # of incomplete credits this term: ___________________

# of credits earned exclusively on-line this term: ________________ # of University Post-Grad degree credits this term: _______________

Yes ____ No _____	WI State owned schools ONLY: Was the WI GI Bill awarded? If so, indicate the amount it paid. $_______________
Yes ____ No _____	Did another military benefit pay this tuition? Indicate benefit ___________________________ & $_______________

Tuition paid by student for satisfactorily completed courses ONLY: $____________________ (NO Segregated fees, books, CEU credits)

Yes ____ No _____	Did the student attain a minimum grade point average of 2.0 for this term/semester (NOT cumulative GPA)?
Yes ____ No _____	Did the applicant have a Bachelor’s Degree or Equivalent prior to the completion of this most recent term?

Certifier’s Signature: ______________________________________ Date: ________________ Telephone: ________________________

MILITARY PORTION: To be certified by the appropriate WIAR-PA-ED or WIAF-DP WI National Guard Office.

Pay Grade: _____ Unit Code: ___________ Enlisted: ______/______/_______ Education Code: _______ ETS: ______/______/_______

Month Day YearMonth Day Year

Certifier’s Signature ______________________________________ Date Certified: ________________ Comment: ___________________

DMA STATE BUDGET & FINANCE PORTION:

DMA FORM 189-E, June 09

Voucher: _____________________Date Processed: _________________ By: ___________