Fillable Printable Cvtg 4363-Application Form
Fillable Printable Cvtg 4363-Application Form
Cvtg 4363-Application Form
Michigan Department of Treasury
4363 (5-12)
Application to Determine Eligibility for Educational Benefits
Children of Veterans Tuition Grant Program
Issued under authority of Public Act 248 of 2005.
Type or print all information. This ap
plication must be completed to apply for educational opportunities provided for
children of certain members of the armed forces of the United States.
Name of Applicant Social Security
N
u
mber
Address (No., Street, P.O. Box or Rural Route) City State ZIP Code
Telephone Number Date of Birth Michigan Resident Since (mm/dd/yyyy)
Name of Surviving Parent or Guardian Relationship
Address City State ZIP Code
Are you receiving benefits from another state? Yes No
If Yes, what state?
Have you ever been convicted of a felony involving an assault, physical injury or death? Yes No
Name of College you plan to attend College Enrollment Date (mm/dd/yyyy)
By my signature, I confirm that the information provided on this form is true and accurate, and I give the above institution permission to release/verify my
academic data for the purposes of this program to the Student Scholarships and Grants. [Required for processing.]
Signature of Applicant Date
Deceased or Disabled Veteran’s Service Record (Parent of the Applicant named above)
Name of Veteran Military Service Number
Date of Entry into Service Date of Separation U.S. Dept. of Veterans Affairs Claim No.
Veteran Affairs Regional Office where claim folder is located
Is the veteran totally and permanently disabled due to service-incurred causes?
Yes (see #4 below) No
Is the veteran’s death due to service-incurred causes?
Yes (see #4 below) No
Required Documentation
Send photocopies only as document s must remain a permanent part of the application.
1. Applicant’s (child’s) birth certificate (must list parents’ names).
2. Veteran’s discharge certificate or separation docume nt (DD Form 214 or Casua l ty Report)
3. Veteran’s death certificate or ca sualty report.
4.
Proof of total and permanent disability or death due to service-in curred ca
uses.
Submit application and required documentation to: Studen t Scholarships and Grants, P.O. Box 30462, Lansing,
MI 48909-7962. Telephone: 1-888-4-GRANTS (1-888-447-2687), extension 3-7120. Fax: 517-241-5835.
