VA educational benefits request for Certification Form

In order to receive military benefits, the Certifying Official at Eastern Iowa Community Colleges (EICC) must certify to the U.S. Department of Veterans Affairs that you have registered for classes.

It is EICC policy that you request certification for each semester that you want to use your benefits. Please fill out the form below to officially request certification.

If you have questions, please contact Lorene Anderson, District VA Certifying Official at 563-441-4035 or landerson@eicc.edu.

Asterisk (*) indicates a response is required.

*First Name:
*Last Name:
*Student ID: (if known)
*E-mail:
*Which benefit are you receiving?

Chapter 30 (Montgomery VA educational benefits for Active Duty)
Chapter 31 (Vocational Rehabilitation and Employment)
Chapter 33 (Post 9/11 VA educational benefits)
Chapter 35 (Survivors and Dependents Educational Assistance)
Chapter 1606 (Selected Reserve MGIB-SR)
*For which semester will you receive this benefit?

Fall Semester
Spring Semester
Summer Semester

It is the policy of Eastern Iowa Community College District not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential family, parental or marital status, as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681-1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact EICC’s Equal Employment Opportunity Officer/Equity Coordinator, Eastern Iowa Community College District, 101 West Third Street, Davenport, Iowa 52801, 563-336-5222, equity@eicc.edu or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730- 1576, TDD (800) 877-8339 OCR.Chicago@ed.gov.