Application for Senior Citizen Fee Remission
Bursar Form 1004 – Revised 04/28/16 PLEASE PRINT CLEARLY
ALL FORMS MUST BE COMPLETED IN FULL IN ORDER TO BE PROCESSED. INCOMPLETE FORMS WILL BE
RETURNED TO APPLICANT. (NEW FORM REQUIRED FOR EACH TERM.)
*ONLY RESIDENTS OF THE STATE OF INDIANA ARE ELIGIBLE FOR THIS REMISSION.*
Name: ____________________________________________ Student ID Number: _____________________________
Date of Birth: _________________________________ Telephone: ____________________________________
Email Address: ____________________________________ Current Employment Status: ______________________
Mailing Address: ___________________________________________________________________________________
Level of High School Completed: _________________ Graduation/GED Date: ___________________________
Full-time (12 or more credit hours) Part-time Degree Seeking Student? YES NO
IF DEGREE SEEKING, and applying for financial aid, the Financial Aid Office is aware of all my financial resources
including this tuition remission.
Term(s) of Planned Enrollment:
Fall 20_____ Spring 20_____ Summer 20_____
Credit Hours: Fall _______ Spring _______ Summer _______
Be at least 60 years old (attach copy of Indiana driver’s license or State ID)
Must have a High School diploma or GED
Be retired or formerly employed full-time and am no longer employed full-time
May enroll full-time or part-time in undergraduate or graduate courses, contingent upon course availability and
Must be an Indiana resident
There is no limit to the number of terms for which a student may receive the tuition remission. The remission is equal to
50% of general service fees and is applicable up to equivalent of 9 credit hours each semester. Special fees, non-resident
tuition correspondence courses, study abroad courses, workshops, media based credit courses and no-credit courses
through Continuing Education and Academic Outreach are not eligible for remission. The addition of the tuition
remission may change existing financial aid awards.
Please forward your completed application to the Bursar’s Office.
The Senior Citizen Tuition Remission is not retroactive for previous terms prior to submission of the application.
I certify by signing below that: (1) I am a resident of the State of Indiana, (2) I am retired, (3) I am not employed on a
full-time basis, (4) I am at least sixty  years old and (5) The above information is correct.
Signature_____________________________________________________ Date __________________________________
Bursar Office Use Only: Date Entered_______________Initials___________
Street Hammond, IN 46323
(219) 989-2560 email@example.com
1401 S. U.S. Hwy. 421 Westville, IN 46391
(219) 785-5338 firstname.lastname@example.org
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