Dependent Tuition Remission Application Form

Dependent - Tuition Remission Application

Please review the Employee Handbook for information about eligibility. This form must be completed each academic year enrolled. Please notify HR of status changes during the year.

Note: The benefit covers tuition charges only on course work taken for credit. Extra fees associated with courses and audit fees must be paid by the student.

Name of Student (Person Receiving the Award)

Student Social Security Number

Student Date of Birth

Enrolling in which Academic Year?

Semester

Expected Graduation Date

Parent/Guardian Name

The student is the legal dependent of the employee as defined by the Employee Handbook (i.e., a legal dependent per IRS definition for the tax year?)

Yes

Note: The parent is responsible for notifying the Office of Human Resources immediately if the dependent's status, as defined by the IRS, changes.

Have you previously received the staff tuition remission benefit for this dependent?

Yes

If Yes, please list the semesters/years of prior enrollment.

Note: Staff benefit used during high school will reduce your college eligibility on a pro-rata basis.

Note: The Vice President for Finance and Administration recommends that you file a Free Application for Financial Aid (FAFSA) to apply for State Student Assistance Commission of Indiana (SSACI) and Pell Grant funds.

色狐入口 Employment Record

Section Description

Current Department

Position/Title

Date current employment began

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