Free s - Indiana

Application for Delayed High School Diploma
Section I - Veteran Information Name of Veteran: __________________________________________ Date of Birth: ______________________ Branch of Military Service: ______________________ Date Joined: ________________________ Date Separated: _______________________________ Name of Last High School Attended: _____________________________ County: _____________ Address of Last High School Attended: ________________________________________________ Was Last School Attended Public or Private School? Public ___________ Private ___________

Years Attended? From 19_____ to 19_____. Date left to begin military service? ______________ Last Grade Attended _________ Date the veteran would have graduated: ________________

If Public School, from which organization does the veteran prefer the diploma to be issued? _______ School shown above ______ County School Corporation if consolidated

______ Indiana State Board of Education

Section II - Living Veteran
Street, P.O. Box, Rural Route: _______________________________________________________ City, State, Zip Code: __________________________________County: _____________________
Living Veteran Certification: I certify that at the time I quit high school I was a student in good standing at the high school indicated above and that I entered the United States Armed Forces prior to the date I would have graduated. (Attach a copy of military separation papers, WD AGO Form or DD Form 214)

___________________________________ (Signature)

___________________ ______________________ (Date) (Telephone No.)

Section III - Deceased Veteran
Date of Death: _________________________ Name of Person Applying: _________________________________ Relationship: _____________ Street, P.O. Box, Rural Route: _______________________________________________________ City, State, Zip Code: __________________________________ County: ____________________
State Form 50900 (5-02)

(continued on reverse side)

Deceased Veteran Certification: I certify that at the time the veteran quit high school he/she was a student in good standing at the high school indicated above and that he/she entered the United States Armed Forces prior to the date he/she would have graduated. (Attach a copy of military separation papers, WD AGO Form or DD Form 214)

__________________________________ (Signature) Mail application and attachments to:

___________________ _______________________ (Date) (Telephone No.)

Indiana Department of Veterans Affairs 302 W. Washington Street E-120 Indianapolis, IN 46204-2738 Applicant: Do not write below this point FOR IDVA USE ONLY _____ Military separation information is verified as accurate and the veteran served during an eligible period and the character of that service was honorable. Application is forwarded to the Indiana Department of Education. _____ Veteran did not serve during an eligible wartime period. Application is returned to the applicant in Section II or Section III. _________________________________________ (Signature) ___________________ (Date)

FOR INDIANA DEPARTMENT OF EDUCATION USE ONLY ______ Applicant wishes to be presented with a diploma from the school or local school corporation shown in Section I. The governing body of the affected school or local school corporation is directed to issue the diploma. ______ Applicant either attended a nonpublic high school before leaving for military service, or has requested a diploma be issued by the board. Diploma will be sent to the applicant indicated in Section II or Section III. _________________________________________ (Signature) ___________________ (Date)

FOR LOCAL SCHOOL CORPORATION USE ONLY County of __________________________ A High School Diploma has been granted for the above named veteran and will be presented at the next graduation ceremony at _____________________________High School.

_________________________________________ (Signature)
State Form 50900 (5-02)

___________________ (Date)