Form DD 2961 DD 2961 Student Complaint Intake

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STUDENT COMPLAINT INTAKE

The public reporting burden for this collection of information is estimated to average XX per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (XXXX-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO:

PRIVACY ACT STATEMENT
AUTHORITY:

N E E D S

D D

PRINCIPAL PURPOSE(S):
ROUTINE USE(S):

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DISCLOSURE:
1. EDUCATION BENEFITS USED (Required) (X all that apply)
GI Bill
Post-9/11 (CH 33)

Survivors & Dependents (DEA: CH 35)

Montgomery (MGIB: CH 30)

Voc Rehab (VR&E: CH 31)

Reserve Educational Assistance Program (REAP: CH 1607)

Veterans Retraining Assistance Program (VRAP)

Select Reserve (SR: CH 1606)

Tuition Assistance Top-Up

Federal Financial Aid
(e.g., Pell Grant)

Military Tuition Assistance (Title 10)
Federal Tuition Assistance (TA)
State Funded Tuition Assistance (National Guard)
Military Spouse Career Advancement Accounts (MYCAA)

2. SCHOOL INFORMATION (Required)
a. SCHOOL NAME (Generic names available for online school, campus sites or DL email)
b. ADDRESS
c. CITY

d. STATE

e. ZIP CODE

f. COUNTRY

g. LEVEL OF STUDY (Select one)

h. TUITION PAID BY YOU OR ANY GOVERNMENT BENEFIT IN THE LAST ACADEMIC YEAR

3. WHICH BEST DESCRIBES YOUR ISSUE? (X all that apply)
Recruiting/Marketing Practices

Accreditation

Unsubstantiated Charges

Student Loans

Post-graduation job opportunities

Sudden change in degree plan/requirements

Quality of Education

Grades

Release of Transcripts

Transfer of Credits

Refund Issues

Other

4. DESCRIBE WHAT HAPPENED SO WE CAN UNDERSTAND THE ISSUE (Required)

DD FORM X640, 20120924 DRAFT

Adobe Professional 8.0

5. WHAT DO YOU THINK WOULD BE A FAIR RESOLUTION TO YOUR ISSUE?

N E E D S

D D

6. STUDENT IS A: (X one)
Veteran

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7. IF VETERAN OR SERVICEMEMBER, BRANCH: (X one)
Spouse or Family Member

Servicemember

Army

Coast Guard

Active Duty

Navy

NOAA/USPS

Reserves

Air Force
Marines

National Guard

8. I AM FILING ON BEHALF OF: (X one)
Myself

Someone else

9. PREFERRED CONTACT INFORMATION
a. SALUTATION (Mr./Ms./
b. FIRST NAME

c. LAST NAME

etc., or military rank)

d. ADDRESS

e. CITY

f. STATE

i. TELEPHONE (Include Area Code)

j. EMAIL ADDRESS

g. ZIP CODE

h. COUNTRY

k. AGE

l. EDUCATION CENTER NAME AND LOCATION

DD FORM X640 (BACK), 20120924 DRAFT

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