Hazlewood Exemption Application for

Those Who Have Previously Received the Exemption (Veterans and Dependents)

at Texas A&M University-Commerce (Form HE-P)

Each person who has previously received an exemption through the Hazlewood Exemption Program (Texas Education Code 54.203) and who wishes to receive an additional exemption through the program must complete and sign the following application and submit it, with proper documentation, to the Hazlewood Administrator of his/her institution.

 Part A. Basic Applicant Data

 1. Name ____________________________    2. Social Security Number: ________________

                  last, first, middle initial

     Student ID: __________________________________________

     Address _____________________________________________

                 _____________________________________________

      Email:   _____________________________________________

      Phone: ______________________________________________

 

 3. Term for which you are applying for the exemption: ___________________/______

                                                                             (fall, spring or summer) / year

 4. Are you applying as a Texas veteran, or as a surviving child of a Texas service member?

[  ] Texas veteran            [  ] child of Texas service member

If applying as the child of a service member:

Name/SSN of deceased parent: ________________________ SSN:_____________

 

 5. Last term in which you used the Hazlewood exemption: ___________________/______

                             fall, spring or summer) / year

 6. Name (not initials) of the last school where you used it: _____________________________

 7. Are you currently in default on an education loan made or guaranteed by the state of Texas or federal government?

   [  ] yes            [  ] no              NOTE: Your answer will be verified by your inst.

 8. Are you currently eligible to receive veterans’ benefits under Title 38, U.S. Code, Chapter 30, 32, 35 or Title 10, U.S. Code, Chapter 1606 or 1607?    [  ] yes           [  ] no

 9. (For veterans only.) Have you served any active duty service since your discharge from the service?     [  ] yes    [  ] no

 Part B. Certification and Consent

My name is ________________________________ and I am applying for an exemption from payment of tuition and certain fees under Texas Education Code, Section 54.203 (The Hazlewood Act). I understand that I may be entitled, under the law, to this exemption for up for 150 hours total at Texas public institutions of higher education. For the purpose of accumulating the total number of hours for which I receive this exemption, I am granting permission to any institution in which I have enrolled or will enroll to release current semester and historic credit hour information to the Texas Higher Education Coordinating Board ("Board") and am granting permission for the Board to share such data with any institution that I might attend. I hereby certify the information I have provided is true and correct and I understand that failure to provide accurate information may result in penalties, including reimbursement to the institution.

 

______________________________________________                         _________________

Signature                                                                                                   Date

 

For Institution Use Only
Approved (initials)________	On file: DD214   DD1300	VA letter on file  [  ] yes   [  ] no
Term VA benefit amnt : $_______	In default:  [  ] no   [  ] yes	Resident now?  [  ] yes   [  ] no