Application for Public Safety Officers' Educational Assistance

Section/Heading	Subheading	Modal?	Question	Field Type	Answer Choices (If applicable)	Required/Not Required	Instructional Text
Public Safety Officers' Education Benefits Prescreen
			In which capacity are you filing for education benefits?	Radio	Student, Student's Parent, Authorized Representative, Other (please describe)	Required
			If "other" selected, describe your filing type:	Text Box	NA	Only required if "other" is chosen as an answer for the previous questions.
Parent, Authorized Representative, or "Other" information.
			Parent, Authorized Representative, or "other" Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Parent, Authorized Representative, or "other" First Name	Text Box	NA	Required
			Parent, Authorized Representative, or "other" Last Name	Text Box	NA	Required
			Parent, Authorized Representative, or "other" Suffix	Text Box	NA	Not Required
			Parent, Authorized Representative, or "other" Phone Number	Text Box	NA	Required
			Parent, Authorized Representative, or "other" Alternate Phone Number	Text Box	NA	Not Required
			Parent, Authorized Representative, or "other" Email	Text Box	NA	Required
Student Information
			Student Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Student First Name	Text Box	NA	Required
			Student Last Name	Text Box	NA	Required
			Student Suffix	Text Box	NA	Not Required
			Student Date of Birth	Text Box/Date Picker	NA	Required
			Student Phone Number	Text Box	NA	Required
			Student Alternate Phone Number	Text Box	NA	Not Required
			Student Email Address	Text Box	NA	Required
Primary Contact Information
			Are you the primary contact person for all matters related to the PSOEA Program?	Radio	Yes/No	Required
Enter the Primary Contact Information
			Primary Contact Person Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Primary Contact Person First Name	Text Box	NA	Required
			Primary Contact Person Last Name	Text Box	NA	Required
			Primary Contact Person Suffix	Text Box	NA	Not Required
			Primary Contact Person Phone Number	Text Box	NA	Required
			Primary Contact Person Alternate Phone Number	Text Box	NA	Not Required
			Primary Contact Person Email Address	Text Box	NA	Required
Student's Record of Education
			Add information about your program of study at an institution of higher education (type of school, dates attended, etc…)
		"Add School" modal					Student's Record of Education
			Name of School	Text Box	NA	Required
			School City	Text Box	NA	Required
			School State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			School Country	Text Box	NA	Not Required
			Type of School	Dropdown	College/University, Vocational/Trade School, Other	Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen) as an answer to the previous question.
			Dates Attended From	Text Box/Date Picker	NA	Required
			Dates Attended To	Text Box/Date Picker	NA	Required
			Degree/Certification Attempting or Achieved	Text Box	NA	Required
			Graduation or Expected Graduation Date	Text Box/Date Picker	NA	Required
Educational Benefits Prescreen	Enter the Public Safety Officer’s information
			Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box		Required (if "other" is chosen)
			Public Safety Officer First Name	Text Box	NA	Required
			Public Safety Officer Last Name	Text Box	NA	Required
			Public Safety Officer Suffix	Text Box	NA	Not Required
			Public Safety Officer's Employing Agency Name	Text Box	NA	Required
			Public Safety Officer Date of Death or Injury	Text Box/Date Picker	NA	Not Required
			Was there an approved Death or Disability claim?	Radio	Yes/No/I don’t know	Required
			Which type of claim was the approved claim?	Radio	Death Claim/Disability Claim	Only required if "yes" chosen as an answer to the previous question.
			Enter PSOB Death or Disability claim number, if known.	Text Box	NA	Not Required
			What is the Student's relationship to the Public Safety Officer?	Radio	Spouse, Child, Other (please describe)	Required
			Describe "other" here:	Text Box	NA	Only required if "other" chosen as an answer to the previous question.
PRESCREEN PREVIEW	Please Review and Confirm						The following is a summary of the information you have entered. Please review and make any necessary changes to this page before submitting your education Prescreen.
Required Documents							Based on your responses, a customized checklist has been generated. The following required documents must be uploaded for the Prescreen to be considered complete. If you have any questions, please contact the PSOB Customer Resource Center at 1-888-744-6513 or [email protected].
			Association	Static Text Box	NA	Auto filled
			Document Type	Static Text Box	NA	Auto filled
			Date Uploaded	Static Text Box	NA	Auto filled
			Instructions	Static Text Box	NA	Auto filled	All doc instructions are located in the "Required Documents and Instructions" tab
			Review Status	Static Text Box	NA	Auto filled
			Add document clarifying notes if necessary.	Text Box	NA	Not Required
			Missing Document Justification	Text Box	NA	Required only if a required document is not uploaded
FINAL REVIEW FORM	Please Review and Confirm						This final review form serves as the version of the Prescreen you are about to submit. If you wish to make edits, return to the editable preview screen to do so.
Public Safety Officers’ Educational Assistance (PSOEA) Prescreen Successfully Submitted							You have successfully submitted your Education Benefits Prescreen, the initial step in applying for PSOEA Program Benefits. An Education Specialist will review your Prescreen to confirm eligibility to apply. After submitting your Prescreen and receiving confirmation to apply, you will be granted access to complete the Public Safety Officers Education Benefits Application. If you have questions about your Education Benefits Prescreen or any of the subsequent steps in filing for these benefits, please do not hesitate to call the PSOB Customer Resource Center at 1-888-744-6513 Monday through Friday between 8:00 AM and 4:30 PM Eastern Standard Time, or email [email protected].
How to Apply for Public Safety Officers’ Educational Assistance (PSOEA) Program Benefits							Eligibility for PSOEA Benefits: Spouses or children of Public Safety Officers whose PSOB death or disability claims have previously been approved are eligible to apply for PSOEA benefits. As a PSOEA applicant, there MUST have been a previously approved PSOB death or disability claim for the applicable Public Safety Officer. Public Safety Officers’ children are no longer eligible for assistance after their 27th birthday, absent a finding of extraordinary circumstances by the Attorney General. Assistance under the PSOEA Program is available for 45 months of full-time education or training or for a proportional period of time for a part-time program.
Application Instructions for PSOEA Benefits:							Step 1: To begin your benefits application for the Public Safety Officers’ Educational Assistance (PSOEA) Program, you must first complete the Education Benefits Prescreen. After clicking the "Prescreen" link below, you will be asked to provide the minimally required materials needed to confirm your eligibility for benefits prior to beginning your Education Benefits Application. Step 2: After submitting your Education Benefits Prescreen and receiving notice that your Prescreen has been accepted, you will be granted access to complete the Education Benefits Application/Term information. After clicking the Application/Term link below, you will be asked to provide further information about your education claim, including evidential documents and educational information.
Public Safety Officers’ Education Benefits Application							Review the information below for accuracy. If the information has changed, please make the alterations where necessary.
			In which capacity are you filing for education benefits?	Radio	Student, Student's Parent, Authorized Representative, Other (please describe)	Required
			If "other" selected, describe your filing type:	Text Box	NA	Only required if "other" is chosen as an answer for the previous questions.
			Parent, Authorized Representative, or "other" Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Parent, Authorized Representative, or "other" First Name	Text Box	NA	Required
			Parent, Authorized Representative, or "other" Last Name	Text Box	NA	Required
			Parent, Authorized Representative, or "other" Suffix	Text Box	NA	Not Required
			Parent, Authorized Representative, or "other" Phone Number	Text Box	NA	Required
			Parent, Authorized Representative, or "other" Alternate Phone Number	Text Box	NA	Not Required
			Parent, Authorized Representative, or "other" Email	Text Box	NA	Required
			Student Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Student First Name	Text Box	NA	Required
			Student Last Name	Text Box	NA	Required
			Student Suffix	Text Box	NA	Not Required
			Student Date of Birth	Text Box/Date Picker	NA	Required
			Student Phone Number	Text Box	NA	Required
			Student Alternate Phone Number	Text Box	NA	Not Required
			Student Email Address	Text Box	NA	Required
			Primary Contact Person Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Are you the primary contact person for all matters related to the PSOEA Program?	Radio	Yes/No	Required
			Primary Contact Person First Name	Text Box	NA	Required
			Primary Contact Person Last Name	Text Box	NA	Required
			Primary Contact Person Suffix	Text Box	NA	Not Required
			Primary Contact Person Phone Number	Text Box	NA	Required
			Primary Contact Person Alternate Phone Number	Text Box	NA	Not Required
			Primary Contact Person Email Address	Text Box	NA	Required
	Student's Record of Education
		"Add School" modal					Student's Record of Education
Education Term Payment	Add school or term information		Name of School	Text Box	NA	Required
			School City	Text Box	NA	Required
			School State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			School Country	Text Box	NA	Not Required
			Type of School	Dropdown	College/University, Vocational/Trade School, Other	Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen) as an answer to the previous question.
			Dates Attended From	Text Box/Date Picker	NA	Required
			Dates Attended To	Text Box/Date Picker	NA	Required
			Degree/Certification Attempting or Achieved	Text Box	NA	Required
			Graduation or Expected Graduation Date	Text Box/Date Picker	NA	Required
Public Safety Officers’ Education Benefits Application							Use the grid below to add information about the educational terms for which you are seeking benefits.
		"Add Term/School" modal
Education Term Payment	Add school or term information		Term	Dropdown	Fall, Spring, Summer, Winter, Other (please describe)	Required
			Describe "other" here:	Text Box	NA	Only required if "other" chosen as an answer to the previous question
			Year	Text Box	NA	Required
			Name of School	Text Box	NA	Required
			City	Text Box	NA	Required
			State/Country	Text Box	NA	Required
			Did you receive any assistance for this term?	Radio	Yes/No	Required
Information about Educational Assistance	Add Educational Assistance						Please list all additional public and private educational assistance you received or will receive for the term(s) for which you are applying. Include assistance such as tuition waivers, grants, or scholarships from public and private sources. Do not list any loans.
		"Add Assistance" modal
			Term	Dropdown	Fall, Spring, Summer, Winter, Other (please describe)	Required
			Describe "other" here:	Text Box	NA	Only required if "other" chosen as an answer to the previous question
			Year	Text Box	NA	Required
			Source/Organization/Institution Name	Text Box	NA	Required
			Amount Received	Text Box	NA	Required
Student Loan Status Verification
			Section 32.35(a) of the PSOEA Regulations states that an individual who is in default on any student loan obtained through Title IV of the Higher Education Act of 1965 will not receive PSOEA benefits unless those benefits are used for repayment of the defaulted loans and the student provides evidence of this in the form of an approved repayment plan. Please select only one from the following:	Radio	I have not obtained any student loans (such as Stafford Loans) through Title IV of the Higher Education Act of 1965. I have obtained students loans (such as Stafford Loans) through Title IV of the Higher Education Act of 1965 but am not in default on any of them. I am currently in default on loans (such as Stafford Loans) obtained through Title IV of the Higher Education Act of 1965. Assistance under the PSOEA Program is to be used for repayment of the defaulted loans and I am submitting an approved repayment plan with this form. I am currently in default on loans (such as Stafford Loans) obtained through Title IV of the Higher Education Act of 1965. I do not have an approved repayment plan.	Required
APPLICATION PREVIEW	Please Review and Confirm						The following is a summary of the information you have entered. Please review and make any necessary changes to this page before submitting your application.
Education Application/Terms	Required Documents						Based on your responses, a customized checklist has been generated. The following required documents must be uploaded for the application to be considered complete. If you have any questions, please contact the PSOB Customer Resource Center at 1-888-744-6513 or [email protected].
			Document Type	Static Text Box	NA	Auto filled
			Association	Static Text Box	NA	Auto filled
			Date Requested	Static Text Box	NA	Auto filled
			Date Uploaded	Static Text Box	NA	Auto filled
			Review Status	Static Text Box	NA	Auto filled
			Instructions	Static Text Box	NA	Auto filled
			Add document clarifying notes if necessary.	Text Box	NA	Not Required
Missing Documents							Your application is missing one or more required documents needed to successfully submit your application. Please go to the previous screen to review the list of required documents, to upload all required documents or to provide an explanation of why a document is missing.
CERTIFICATION OF APPLICATION/TERM							I certify that all information set forth above is true to the best of my knowledge and belief. I authorize the release of school records to the Department of Justice for the sole purpose of administering the PSOEA Program. I understand that I must provide the PSOB Office with a copy of my transcript each time I apply for benefits, and that failure to maintain satisfactory progress may result in a loss of additional assistance. I certify that the PSOEA benefits being provided to me will only be used for educational or vocational purposes consistent with 42 USC § 3796d and 28 CFR § 32. I further certify that I am not in default on any student loans provided or guaranteed by the United States Government. I know of no facts or circumstances that would render the person identified here as ineligible for the benefit. I understand that knowingly and willfully making a false or incomplete statement or failing to fully disclose pertinent information concerning this claim may be grounds for non-payment of benefits or for prosecution for a false statement under 18 U.S.C. § 1001.
			Checking this box asserts that all of the information you provided on this form is true and correct, and will be treated as an electronic signature by the applicant.	Checkbox	NA	Required
FINAL REVIEW FORM	Please Review and Confirm						This final review form serves as the version of the application you are about to submit. If you wish to make edits, return to the editable preview screen to do so.
Public Safety Officers’ Education Assistance (PSOEA) Program - Successful Submission of Term Documents	Public Safety Officers’ Education Assistance (PSOEA) Program - Successful Submission of Term Documents						You have successfully submitted your term documents as part of your PSOEA Application. An Education Specialist will review your expense-related documentation to confirm that you have provided all the required documents needed to assess your eligibility for educational assistance. If you have questions about your PSOEA Application or any of the subsequent steps in filing for Education Benefits, please do not hesitate to call the PSOB Customer Resource Center at 1-888-744-6513 Monday through Friday between 8:00 AM and 4:30 PM Eastern Standard Time, or email [email protected].