M:\Work\Adobe PDFs\radio button DEPENDENT APPLICATION FOR TUITION DISCOUNT 4.20.20 (1).docx
Signature of Employee
Director of Human Resources or Designee
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:
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.
Please Circle
(If YES, attach copy of top portion of federal form 1040 for prior year showing dependents claimed)
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