CALIFORNIA DEPARTMENT OF VETERANS AFFAIRS
COLLEGE FEE WAIVER PROGRAM FOR VETERANS DEPENDENTS
PLEASE READ THE INSTRUCTIONS AND INFORMATION
CONTAINED ON THE REVERSE SIDE
I.STUDENT INFORMATION
Last Name:___________________________First:____________________ MI:_____ Social Security Number:________ -_______-____________
Date of Birth: ____/____/___ Phone #: ( )_____--________ Marital Status: Married Single Student E-mail: ___________________
Street Address: ______________________________________________City: _________________________State: ________ Zip: _____________
STUDENT’S relationship to veteran in Section III below: ______________________________________________
HAVE YOU APPLIED FOR THIS BENEFIT BEFORE? YES NO
ARE YOU receiving, OR ARE YOU CURRENTLY eligible to receive VA EDUCATIONAL BENEFITS UNDER CHAPTER 35? YES NO
ADJUSTED GROSS INCOME (AGI) of student from last year (January 1st through December 31st): $______________________
*NOTE: Refer to “ HOW TO APPLY” on the reverse for required statements.
ANNUAL VALUE OF SUPPORT received from a parent: $ ____________________________ *NOTE: if entering $0.0 you must attach an explanation)
*Note: examples of support include, but are not limited to: college housing, transportation, books, school supplies, medical care etc…
Note: 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.
II.SCHOOL INFORMATION
CALIFORNIA COLLEGE or UNIVERSITY you are attending or plan to attend: ________________________________________
ACADEMIC YEAR for which you are requesting waiver of tuition/fees: ________________________________________________
III.VETERAN INFORMATION
Name served under: Last Name: ___________________________________ First: _____________________________ MI: ________
Street Address: ___________________________________________City: ______________________ __State: _______Zip: _________
Telephone Number: (___)_________-__________ Branch of Service: ______________ VETERAN’S E-mail: ___________________
Date of Birth: ________/_____/_______ Date of Death (if applicable):_____/_____/_____ VA Claim #:______-______-_______
Dates of Active Duty service FROM: _______________ UNTIL: ______________ Service#/SSN#:__________________________
If the veteran is alive, current percentage of service-connected disability adjudicated by the military or USDVA: _________%
If the veteran is deceased, was the death "service-connected," or did the veteran have a service-connected disability at the time of death?
I hereby certify under penalty 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 (CDVA) employees, officers, and designees to verify these documents. I hereby authorize the U.S. Department of Veterans Affairs, Department of Defense, Employment Development Department and the Franchise Tax Board, to release information regarding my service-connected disability rating and/or income to CDVA with the understanding that the department will keep such information confidential. Further, I understand that educational benefits may be denied if any information is found to be incomplete or inaccurate.
Signature of VETERAN (or Parent if Veteran not available): _________________________________________ Date: ________/________/_______
(If Parent or Veteran is unable to sign, a statement as to why the veteran is unavailable must be attached)
Signature of STUDENT: ___________________________________________________________________ |
Date: ________/________/_______ |
DVS-40 (4/16)
WHAT ARE THE BENEFITS?
Waiver of all mandatory system wide tuition and fees at any State of California Community College, Campus of the University of California,
or Campus of the California State University system.
WHO MAY APPLY?
1 – Students must meet the California residency requirements as determined by the school they will attend.
2 - Students who meet the requirements of at least one of the following plans:
PLAN A: The spouse, child or unmarried surviving spouse or California certified registered domestic partner (RDP) of a veteran who is totally service-connected disabled or who has died of service-related causes, may qualify. The veteran must have served during a period of war declared by Congress, or been awarded a Campaign or Expeditionary Medal. This program does not have an income limit. A child must be under 27 years of age to receive the fee waiver benefit. The age limit is extended to 30 years of age if the child is a veteran. There are no age limits for a spouse, surviving spouse or RDP. *Note: a dependent cannot receive this benefit if they are in receipt of VA Chapter 35 benefits,
OR,
PLAN B: The child (no age limit) of a veteran who has a service-connected disability, or had a service-connected disability at the time of death, or who died of service-related causes, may also qualify for a waiver of fees. The child’s income, which includes the
student’s ADJUSTED GROSS INCOME, PLUS THE VALUE OF SUPPORT provided by a parent, cannot exceed the “national poverty level” as published by the U.S. Census Bureau on December 31st of last year. *NOTE: This figure changes
annually. To obtain the applicable national poverty level, contact your local County Veterans Service Office (CVSO).
OR,
PLAN C: Any dependent, non-remarried surviving spouse, or current RDP of a member of the California National Guard who was killed, permanently disabled or died of this disability that resulted from activation under Military and Veterans Code Section 146. OR
PLAN D: Plan D Benefits are available to Congressional Medal of Honor recipients and their children.
HOW TO APPLY:
(1)This form must be fully completed, signed by the student and the veteran (or parent, but you must explain why the veteran is not available), and all questions must be answered. If a question does not apply, write "N/A”. If neither parent is available to sign, please attach an explanation.
(2)A Child, under PLAN B, must submit either a copy of their federal income tax form 1040 or state income tax form 540, from "Last Year" or, if a child does not have a copy of their income tax, or if a child did not file a return, they must submit a statement from the Internal Revenue Service (800-829-1040) or the Franchise
Tax Board (800-852-5711) which must verify the amount of adjusted gross income or the fact that a return was not filed. **NOTE**: Current academic year
entitlement is based upon last year’s adjusted gross income and value of support. For Example: If applying for benefits for academic year 2015-2016, the total amount of your reported adjusted gross income and value of support from calendar year 2014 will be used to determine eligibility.
(3)If you are a "child" of a veteran, you must attach a Verification of Dependency. Acceptable verifications include, but are not limited to, a Birth
Certificate, Adoption Records or a Court Order. Those seeking status as an Adopted Child or as a Stepchild must have entered into such status prior to the child’s 18th Birthday. Adopted and stepchild status after the child’s 18th birthday is only valid if the child has continuously been in school since the age of 18 (transcripts must be provided), and for stepchildren they must be a member of the veteran’s household.
WHEN TO APPLY:
Always try to apply for these benefits prior to attending school. Benefits are awarded on an academic year basis and students are required to reapply each year for ongoing benefits. NOTE: The earliest effective date fee waiver benefits may be awarded is the first day of the academic year in which an application is received.
WHERE TO APPLY:
To obtain an application, additional information and to apply for benefits under this program, contact your local County Veterans Service Office at: www.cacvso.org.
“If eligibility criteria are met, use of the California College Fee Waiver for Veterans Dependents may be applied to state-supported programs in the CCC, CSU, and UC systems. Some academic programs at these institutions that are considered self-supported, commonly referred to as extension courses or extended education are not covered under the Fee Waiver because these courses, degrees, and certificates are neither funded by the state nor are they system-wide programs.
Veteran’s dependents applying for this waiver should research their academic programs thoroughly before applying to the college or university.”
YOU MAY BE ENTITLED TO ADDITIONAL VETERANS BENEFITS
TO LEARN MORE ABOUT THE BENEFITS YOU HAVE EARNED, VISIT:
www.cacvso.org or www.calvet.ca.gov
PRIVACY NOTIFICATION
The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals. Information requested on this form is voluntary and will be used for the purposes of identification and to determine eligibility for benefits under the provisions of the Military and Veterans Code, Sections 890 through 899 and 980 and Education Code, Section 66025.3. The program is administered by: Deputy Secretary, Veterans Services Division, 1227 "O" Street, Sacramento, CA 95814. Failure to provide requested information will result in the delay or denial of benefits. Individuals may review available personal records during normal business hours. Appeals of denied benefits shall be filed with the Veterans Services Division (note address above). Appeals must be in writing, stating the reasons you feel the benefits should be granted, and filed within 90 days after the date of the "letter of denial."
DVS-40 (4/16)
