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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
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