Free 53705.pdf - Indiana


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2009-2010 REMISSION OF FEES APPLICATION FOR INDIANA PURPLE HEART VETERANS
State Form 53705 (R2 / 6-09)

*

This agency is requesting disclosure of your Social Security Number (SSN) in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

Applicants must also annually file a Free Application for Federal Student Aid (FAFSA), preferably by the State Student Assistance Commission of Indiana's (SSACI) published deadline. You can file your FAFSA online at www.FAFSA.ed.gov. The application must be completed in INK else it will not be processed. There are four sections and three pages to this application: Read the PROGRAM ELIGIBLITY TERMS & FILING INSTRUCTIONS in SECTION 2 and 3 of this application. It's recommended that you make copies of the application/instructions, for your records once it's returned to you by the Indiana Department of Veteran's Affairs (IDVA).

BEFORE YOU START: · Indiana must have been your home of record at your initial entry in to the Armed Forces and have received a Purple Heart to qualify for this program. · Read SECTION 2, PROGRAM ELIGIBLITY TERMS, before proceeding. · Check YES only if you have read and meet the PROGRAM ELIGIBLITY TERMS described in SECTION 2: YES NO · If you checked YES, then you must attach Purple Heart Documentation to this application. If you answered NO then you are not eligible for this program; do not complete and submit this Application.

SECTION 1

PURPLE HEART RECIPIENT DATA
THIS MUST BE COMPLETED IN INK. PLEASE PRINT CLEARLY.

1. First Name: _____________________ Middle Name: ______________________ Last Name: _________________________ 2. Social Security Number: ________ - ________ - __________ Date of Birth (m/d/yy): ______ / ______ / ______ 3. Branch of service ________________________________________ 4. Dates of service: From (m/d/yy): ______ / ______ / ______ To (m/d/yy): ______ / ______ / ______ 5. Recipient's Address: _________________________________ City: ________________ State: ________ ZIP: ____________ 6. Telephone Number: ( ______ ) ______ - __________ 7. Was Indiana your home of record at the time of your initial entry in to the armed forces? YES NO 8. List the Code number of public college you'll attend (colleges are listed in SECTION 4): #_______ Start Date (m/yy): ____ / ____ 9. Check the degree type this application/these benefits will be used toward: (a) Undergraduate (b) Graduate 10. Indicate whether you will attend the college listed in Question #8 full or part time: (a) Full Time (b) Part Time 11. By signing and dating this application, I certify that the above statements are true and correct and that if asked I will provide documentation to verify its accuracy. I also agree that I have read and understand the PROGRAM ELIGIBLITY TERMS & Filing Instructions in SECTIONS 2 and 3. I understand that I can be fined, prosecuted or both if I have provided false or misleading information as it relates to this application and my eligibility for this program. Recipient Signature: ______________________________________ Date of Application: (m/d/yy) ______ / ______ / ______

*FOR IDVA USE ONLY* ***IDVA VERIFICATION*** *FOR IDVA USE ONLY* APPPROVED NOT APPROVED Indiana was/is home of record at time of initial entry Applicant does not meet Indiana residency requirements Honorable discharge Cannot verify honorable discharge Awarded Military Order of the Purple Heart Cannot verify award of the Purple Heart received

IDVA VERIFICATION SIGNATURE: _________________________________________
Not Valid Without Embossed IDVA Seal.

Date (m/d/yy): ___________________

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SECTION 2

PROGRAM ELIGIBLITY TERMS
Read and Retain for Your Records.

REMISSION OF FEES FOR INDIANA PURPLE HEART VETERANS
The Indiana General Assembly established defined educational benefits for the recipients of the Military Order of the Purple Heart. The applicant must be a person who enters active duty service from a permanent home address in Indiana, receives an honorable discharge, and receives the Purple Heart decoration for that active duty service. The benefit covers up to 124 credit hours of undergraduate or graduate tuition and regularly assessed mandatory fees to attend a state-supported college at the undergraduate rate of that institution. Only the public institutions listed in SECTION 4 of this application are eligible for this benefit and the 124 hours covered includes any combination of direct remissions provided by the college and any tuition and fee grants aid paid on your behalf by the state of Indiana. ELIGIBLITY SUMMARY Applicants must: · Be a person who entered active duty service from a permanent home address in Indiana. · Have received an honorable discharge. · Have received a Military Order of the Purple Heart decoration for that active duty service. · Be declared by the college as a resident of the State of Indiana and eligible for Indiana in-state tuition. · Annually file the appropriate (error-free) academic year's (AY) Free Application for Federal Student Aid (FAFSA). · Attend one of the Indiana public colleges/universities as listed in SECTION 3. Courses must be for college credit; continuing education courses are not covered under this program. · Maintain Satisfactory Academic Progress (SAP) as determined by the college. · Not be in default of a student loan or overpayment of a state or federal grant.

SECTION 3

FILING INSTRUCTIONS

HOW TO APPLY · In addition to this application, you must annually file a current year Free Application for Federal Student Aid (FAFSA). · Answer all questions on this application (lines 1 through 10) IN INK. PRINT CLEARLY. The student should be accepted by the college listed in Question #8 prior to application. Incomplete applications will be returned to you without processing. · Mail your completed 2009-2010 REMISSION OF FEES APPLICATION FOR INDIANA PURPLE HEART VETERANS to: The Indiana Department of Veterans Affairs (IDVA) 302 West Washington Street, Room E-120, Indianapolis, IN 46204-2738 · IDVA will verify service-related information to determine eligibility for tuition and fee remission benefits under this program. WHAT HAPPENS AFTER IDVA VERIFICATION · After IDVA verifies the veteran's period of service, discharge status and related information insofar as eligibility for this program is concerned, they will approve or deny the application and return it to the address provided in SECTION 1. · Submit the IDVA-approved application to your college's Financial Aid Office; they will apply your remission of fees/state financial aid accordingly. · You must file a new application for tuition remission/grants when you: Change colleges, or Stop out of college for two or more semesters. Students who stop out of college for two or more semesters are considered "new" applicants and as such will be covered by program terms that apply to all new applicants. IMPORTANT NOTES REGARDING VERIFICATION The recipient must, upon request, provide to IDVA and/or the college any relevant information to support/verify eligibility for program benefits including but not limited to three years worth of Indiana state income tax returns. WHO TO CONTACT Questions on eligibility should be directed to the Indiana Department of Veterans Affairs, 317/232-3910 or 800/400-4520, or FAX at 317/232-7721. All questions related to fee remission credits, including an historical account of hours used under the program, should be directed to the financial aid office of the institution the recipient attends.

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SECTION 4

THE COMPLETE LIST OF ELIGIBLE INDIANA PUBLIC INSTITUTIONS

Those eligible to receive tuition remissions under the Application for Remission of Fees for Indiana Purple Heart Veterans program must be admitted and enrolled at one of the following Indiana public colleges and universities listed below:
School Ball State University Indiana State University IU Bloomington IU East IUPU Indianapolis IUPU Columbus IU Kokomo IU Northwest IU South Bend IU Southeast Code 001786 001807 001809 001811 001813 E01033 001814 001815 001816 001817 School Purdue University, West Lafayette Purdue North Central Purdue Calumet Indiana Purdue Fort Wayne IVY Tech Bloomington IVY Tech Columbus IVY Tech Evansville / Tell City IVY Tech Fort Wayne IVY Tech Gary / Valpo. / E. Chicago IVY Tech Indianapolis Code 001825 001826 001827 001828 035213 010038 009925 009926 010040 009917 School IVY Tech Kokomo / Logansport / Wabash IVY Tech Lafayette / Crawfordsville IVY Tech Madison / Lawrenceburg IVY Tech Muncie / Anderson / Marion IVY Tech Richmond / Connersville IVY Tech Sellersburg IVY Tech South Bend / Warsaw / Elkhart IVY Tech Terre Haute / Greencastle University of Southern Indiana Vincennes University Code 010041 010039 009923 009924 010037 010109 008423 008547 001808 001843

Questions should be directed to the Indiana Department of Veterans Affairs at: (317) 232-3910, or (800) 400-4520.
This form cannot and will not be returned to the Veteran by FAX.

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