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REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM CONTROL NUMBER For use of this form, see AR 621-5; the proponent agency is DCSPER DATA REQUIRED BY THE PRIVACY ACT OF 1974 AUTHORITY Title 10 USC 2007; Title 10 USC 2005 PRINCIPAL PURPOSE(S) Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who, due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse the Army an amount equal to the tuition assistance received. ROUTINE USES Used as a record of courses in progress for which the service member is receiving tuition assistance. Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for reasons within his or her control. DISCLOSURE Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a service member who fails to complete courses for reasons within his or her control. APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN 1. APPLICANT'S NAME (Last, First, MI) 4. MOS 6A. NAME OF SCHOOL 6B. ADDRESS OF SCHOOL (Include ZIP Code) 6C. LOCATION OF CLASS 6D. PURPOSE (Formally Declared Goal) 7. Course Data 5. DEPARTMENT AND COURSE NUMBER A 2. SSN 3. ETS ORGANIZATION AND LOCATION OF ASSIGNMENT TITLE OF COURSES DAYS OF WEEK HOURS OF MEETING B C D 8B. NUMBER OF SEMESTER OR QUARTER HOURS E CREDIT HOUR COST F 9. COURSE COST LESS FEES AND BOOKS G AMOUNT PAID H 8A. COURSE BEGINS 10. I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO. A. SIGNATURE OF APPLICANT 11. Applicant's Unit Commander or Authorized Representative COURSE ENDS B. COST TO GOV'T OFFICE TELEPHONE NUMBER C. DATE Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2; and anticipated duties will permit class attendance. A. TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE B. SIGNATURE C. DATE 12. Tuition Assistance in the Amount Indicated in Item 9 Above is Approved A. TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER B. SIGNATURE C. DATE 13. Fiscal A. CONTRACT NUMBER B. CHARGEABLE TO ORDER NUMBER C. ACCOUNTING CLASSIFICATION D. INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade reports within 30 days of course completion. DA FORM 2171, APR 89 Copy 1 - Institution USAPPC V1.00 REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM CONTROL NUMBER For use of this form, see AR 621-5; the proponent agency is DCSPER DATA REQUIRED BY THE PRIVACY ACT OF 1974 AUTHORITY Title 10 USC 2007; Title 10 USC 2005 PRINCIPAL PURPOSE(S) Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who, due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse the Army an amount equal to the tuition assistance received. ROUTINE USES Used as a record of courses in progress for which the service member is receiving tuition assistance. Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for reasons within his or her control. DISCLOSURE Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a service member who fails to complete courses for reasons within his or her control. APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN 1. APPLICANT'S NAME (Last, First, MI) 4. MOS 6A. NAME OF SCHOOL 6B. ADDRESS OF SCHOOL (Include ZIP Code) 6C. LOCATION OF CLASS 6D. PURPOSE (Formally Declared Goal) 7. Course Data 5. DEPARTMENT AND COURSE NUMBER A 2. SSN 3. ETS ORGANIZATION AND LOCATION OF ASSIGNMENT TITLE OF COURSES DAYS OF WEEK HOURS OF MEETING B C D 8B. NUMBER OF SEMESTER OR QUARTER HOURS E CREDIT HOUR COST F 9. COURSE COST LESS FEES AND BOOKS G AMOUNT PAID H 8A. COURSE BEGINS 10. I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO. A. SIGNATURE OF APPLICANT 11. Applicant's Unit Commander or Authorized Representative COURSE ENDS B. COST TO GOV'T OFFICE TELEPHONE NUMBER C. DATE Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2; and anticipated duties will permit class attendance. A. TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE B. SIGNATURE C. DATE 12. Tuition Assistance in the Amount Indicated in Item 9 Above is Approved A. TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER B. SIGNATURE C. DATE 13. Fiscal A. CONTRACT NUMBER B. CHARGEABLE TO ORDER NUMBER C. ACCOUNTING CLASSIFICATION D. INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade reports within 30 days of course completion. DA FORM 2171, APR 89 Copy 2 - Commercial Accounts, Finance and Accounting Office (F&AO) USAPPC V1.00 REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM CONTROL NUMBER For use of this form, see AR 621-5; the proponent agency is DCSPER DATA REQUIRED BY THE PRIVACY ACT OF 1974 AUTHORITY Title 10 USC 2007; Title 10 USC 2005 PRINCIPAL PURPOSE(S) Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who, due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse the Army an amount equal to the tuition assistance received. ROUTINE USES Used as a record of courses in progress for which the service member is receiving tuition assistance. Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for reasons within his or her control. DISCLOSURE Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a service member who fails to complete courses for reasons within his or her control. APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN 1. APPLICANT'S NAME (Last, First, MI) 4. MOS 6A. NAME OF SCHOOL 6B. ADDRESS OF SCHOOL (Include ZIP Code) 6C. LOCATION OF CLASS 6D. PURPOSE (Formally Declared Goal) 7. Course Data 5. DEPARTMENT AND COURSE NUMBER A 2. SSN 3. ETS ORGANIZATION AND LOCATION OF ASSIGNMENT TITLE OF COURSES DAYS OF WEEK HOURS OF MEETING B C D 8B. NUMBER OF SEMESTER OR QUARTER HOURS E CREDIT HOUR COST F 9. COURSE COST LESS FEES AND BOOKS G AMOUNT PAID H 8A. COURSE BEGINS 10. I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO. A. SIGNATURE OF APPLICANT 11. Applicant's Unit Commander or Authorized Representative COURSE ENDS B. COST TO GOV'T OFFICE TELEPHONE NUMBER C. DATE Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2; and anticipated duties will permit class attendance. A. TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE B. SIGNATURE C. DATE 12. Tuition Assistance in the Amount Indicated in Item 9 Above is Approved A. TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER B. SIGNATURE C. DATE 13. Fiscal A. CONTRACT NUMBER B. CHARGEABLE TO ORDER NUMBER C. ACCOUNTING CLASSIFICATION D. INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade reports within 30 days of course completion. DA FORM 2171, APR 89 Copy 3 - Accounting Division Accounts Maintenance Activity (F&AO) USAPPC V1.00 CONTROL NUMBER REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM For use of this form, see AR 621-5; the proponent agency is DCSPER DATA REQUIRED BY THE PRIVACY ACT OF 1974 AUTHORITY Title 10 USC 2007; Title 10 USC 2005 PRINCIPAL PURPOSE(S) Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who, due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse the Army an amount equal to the tuition assistance received. ROUTINE USES Used as a record of courses in progress for which the service member is receiving tuition assistance. Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for reasons within his or her control. DISCLOSURE Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a service member who fails to complete courses for reasons within his or her control. APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN 1. APPLICANT'S NAME (Last, First, MI) 4. MOS 6A. NAME OF SCHOOL 6B. ADDRESS OF SCHOOL (Include ZIP Code) 6C. LOCATION OF CLASS 6D. PURPOSE (Formally Declared Goal) 7. Course Data 5. DEPARTMENT AND COURSE NUMBER A 2. SSN 3. ETS ORGANIZATION AND LOCATION OF ASSIGNMENT TITLE OF COURSES DAYS OF WEEK HOURS OF MEETING B C D 8B. NUMBER OF SEMESTER OR QUARTER HOURS E CREDIT HOUR COST F 9. COURSE COST LESS FEES AND BOOKS G AMOUNT PAID H 8A. COURSE BEGINS 10. I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO. A. SIGNATURE OF APPLICANT 11. Applicant's Unit Commander or Authorized Representative COURSE ENDS B. COST TO GOV'T OFFICE TELEPHONE NUMBER C. DATE Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2; and anticipated duties will permit class attendance. A. TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE B. SIGNATURE C. DATE 12. Tuition Assistance in the Amount Indicated in Item 9 Above is Approved A. TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER B. SIGNATURE C. DATE 13. Fiscal A. CONTRACT NUMBER B. CHARGEABLE TO ORDER NUMBER C. ACCOUNTING CLASSIFICATION D. INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade reports within 30 days of course completion. DA FORM 2171, APR 89 Copy 4 - AEC Suspense File USAPPC V1.00 REQUEST FOR TUITION ASSISTANCE - ARMY CONTINUING EDUCATION SYSTEM CONTROL NUMBER For use of this form, see AR 621-5; the proponent agency is DCSPER DATA REQUIRED BY THE PRIVACY ACT OF 1974 AUTHORITY Title 10 USC 2007; Title 10 USC 2005 PRINCIPAL PURPOSE(S) Used to show courses for which the service member is receiving tuition assistance from the Army. Service members who, due to reasons within their control, fail to complete a course for which they are receiving tuition assistance must reimburse the Army an amount equal to the tuition assistance received. ROUTINE USES Used as a record of courses in progress for which the service member is receiving tuition assistance. Used as a means by which the Army can recoup monies for courses which the service member has failed to complete for reasons within his or her control. DISCLOSURE Disclosure of information is mandatory. DA Form 2171 is the only authority which can be used to recoup monies from a service member who fails to complete courses for reasons within his or her control. APPLICANT WILL COMPLETE ITEMS 1 THROUGH 10. USE TYPEWRITER, IF POSSIBLE, OTHERWISE HEAVY PEN 1. APPLICANT'S NAME (Last, First, MI) 4. MOS 6A. NAME OF SCHOOL 6B. ADDRESS OF SCHOOL (Include ZIP Code) 6C. LOCATION OF CLASS 6D. PURPOSE (Formally Declared Goal) 7. Course Data 5. DEPARTMENT AND COURSE NUMBER A 2. SSN 3. ETS ORGANIZATION AND LOCATION OF ASSIGNMENT TITLE OF COURSES DAYS OF WEEK HOURS OF MEETING B C D 8B. NUMBER OF SEMESTER OR QUARTER HOURS E CREDIT HOUR COST F 9. COURSE COST LESS FEES AND BOOKS G AMOUNT PAID H 8A. COURSE BEGINS 10. I have read the pertinent portions of AR 621-5 and I am eligible for tuition assistance. I am required to comply with policies and procedures set forth therein. I understand that tuition assistance is authorized on a course-by-course basis and any additional agreements between educational institutions and me are not binding to the Army. I authorize the institution's to forward a copy of my grade report to the ESO. A. SIGNATURE OF APPLICANT 11. Applicant's Unit Commander or Authorized Representative COURSE ENDS B. COST TO GOV'T OFFICE TELEPHONE NUMBER C. DATE Courses listed above have specific relevance and/or general value to the Army. Soldier has potential for continued service; is not flagged IAW AR 600-8-2; and anticipated duties will permit class attendance. A. TYPED NAME OF APPLICANT'S UNIT COMMANDER OR AUTHORIZED REPRESENTATIVE B. SIGNATURE C. DATE 12. Tuition Assistance in the Amount Indicated in Item 9 Above is Approved A. TYPED NAME OF CONTRACTING OFFICER'S REPRESENTATIVE OR EDUCATION SERVICES OFFICER B. SIGNATURE C. DATE 13. Fiscal A. CONTRACT NUMBER B. CHARGEABLE TO ORDER NUMBER C. ACCOUNTING CLASSIFICATION D. INSTITUTIONS WILL MAIL INVOICES AND GRADE REPORTS TO By accepting tuition assistance for payment, institution agrees to notify ESO of course withdrawal within five days and submit to ESO official grade reports within 30 days of course completion. DA FORM 2171, APR 89 Copy 5 - DA Form 669 or soldier USAPPC V1.00