Kdva Form Tw 4 – Fill Out and Use This PDF

Kentucky Department of Veterans Affairs

Application for Extension of Tuition Waiver Benefit

1.First Name _____________________ MI _________________ Last Name __________________________

2.Address __________________________ City ____________________ KY Zip Code ___________________

3.Date of Birth _________________ SSN_____________________ Telephone ________________________

4 Name of state supported institution of higher learning __________________________________________

5.Current Tuition Waiver Certificate number: ___________________________________________________

6. If spouse of deceased veteran, are you remarried?

_______ Yes

_______ No

Applicant Certification

I certify that I, the above named applicant, have not obtained a diploma or certificate of completion from a school or institution of higher learning while using the Kentucky Tuition Waiver benefit. I hereby certify, under penalty of law, that the information given in this application is correct and complete to the best of my knowledge. I am aware that, should investigation at any time show falsification, I will be disqualified from future eligibility for Tuition Waiver. I hereby authorize the Kentucky Department of Veterans Affairs and agencies to which my name is certified or referred to make all necessary investigations concerning my status, eligibility, or action in any transaction. I authorize the Kentucky Department of Veterans Affairs to receive and make available to state institutions of higher learning my records attached in support of this application, and further authorize and request each institution, agency or organization to provide all information that may be sought in connection with my application.

Signature of Applicant: ______________________________________ Date: _____________________

Institution of Higher Learning

I certify the above named applicant has not obtained a diploma or certificate of completion while using the Kentucky Tuition Waiver benefit.

Name of institution of higher learning _____________________________________________________

Printed name of official from Registrar’s Office ______________________________________________

Signature: __________________________________ Telephone Number: _______________________

KDVA Office Use Only

Approved/Disapproved: _____________________________________ Date: __________________

Effective Date: _______________________

KRS 164.507 ___________

KRS 164.515 __________ Certificate Number: _____________

KDVA Form TW 4 – May 2007