APPLICATION FOR DEPENDENT TUITION DISCOUNT
Employee Name Dependent Name (includes spouse)
Department Relationship
Employee’s ID A Dependent’s Student ID A
Employee’s Class A/P Faculty ESP Dependent’s Date of Birth
EMPLOYEE to complete the following for dependent taking course(s):
Indicate semester and number of credits dependent intends to enroll in:
Semester: Number of Credits:
If applicable (Spouses of eligible employees and unmarried children or stepchildren under the age of twenty-five (25) will be considered eligible regardless of
whether they meet the IRS definition of dependency. For all other dependents, the prior year's federal tax declaration form (1040) or a birth certificate will be required
as documentation) was dependent declared as such on your previous year’s tax form?
Yes No N/A
I affirm that the above is true: Date
HUMAN RESOURCES: Verification of dependency documentation and Employee Class A/P, ESP or Faculty.
Director of HR’s signature: Date
Faculty Percentage according to Faculty Contract:
Faculty members with less than three full years of employment: Eligible individuals will pay 50%.
Faculty members with three or more full years of employment: Eligible individuals will pay 45% in year one (AY
19/20) of the agreement, 40% in year two (AY 20/21), and 35% in subsequent years.
REGISTRAR: Verification of enrollment in courses (list total credits each semester).
Semester: Total Credits:
Do the above courses apply for credit towards a baccalaureate degree? Yes No
Registrar or Designee:
FINANCIAL AID:
Tuition Cost Enrollment Fee Other Adjustments 50% Discount Applied Approval
*Tuition adjustments to individuals who have already earned a baccalaureate degree may be subject to taxation and may need to be declared as income. Check with
your tax consultant.
