Fillable Application for Staff Child or Staff Spouse Fee (Purdue University Northwest)

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Application for Staff Child or Staff Spouse Fee (Purdue University Northwest)

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BURSAR OFFICE
Application for Staff Child or Staff Spouse Fee Remission
Bursar Office Form 1015 – Revised 10/18/16 Please Print Clearly
All Forms Must Be Completed In Full In Order To Be Processed. Incomplete Forms Will Be Returned To Staff
Member. (New Form Required For Each Term.)
Section A – General Information (All applicants must complete this section.)
Employee Name: ________________________________________ Employee PUID: _____________________________
Employee Department: ___________________________________ Date of Employment: ________\_______\_________
Employing Campus: _____________________________________ Employee Status: (Check One Below.)
Admin/Faculty Clerical/Service Graduate Staff Official Retiree
Type of fee remission requested: (Check One) Child Spouse
(Complete Section B) (Complete Section C)
For: Fall 20_____ Spring 20_____ Summer 20_____ Campus_________________________
Section B – Complete for Staff Child Remission Only
I certify that the child is my dependent, based upon the definitions provided on the reverse of this document, (under
the staff child remit provisions).
I meet all the requirements for receiving the fee remit, however, the applicant is no longer a dependent and I am
aware of the tax implications this entails as noted on the last page of this form (Taxable Remission Information).
Name of Staff Child (In Full): _____________________________________________________________________________
Staff Child’s PUID: ____________________________________________________ Birth Date:______\_______\_______
Has the Staff Child earned a baccalaureate or professional degree from any institution prior to this application?
Yes No
Is the Staff Child less than 26 years old?
Yes No
Will Staff Child be working toward a degree at Purdue Northwest? Yes No (where)_____________________
School and Curriculum in which Staff Child will be registered: __________________________________________________
Is this applicant your: (Check One) Child Step Child Ward
(If you checked Ward on the above line, please provide a copy of your court documents with the application.)
Home address of Parent or Legal Guardian:
______________________________________________________________________
Has Staff Child been registered as a Purdue student prior to this application for fee remission? Yes No
If Yes, state number of additional semesters needed for graduation: ______________________________
If No, when will remission first be used: (Semester/Year) ____________________________________________
Section C – Complete for Staff Spouse Remission Only
Has Staff Member been employed in an eligible position continuously (without breaks in employment) for two or
more years? Yes No
Name of Staff Spouse (In Full):_______________________________________________________________________________
Staff Spouse PUID:_______________________________ Begin Date of Marriage:_______\_______\_______
Hammond Campus
2200 169th Street * Hammond, IN 46323
(219) 989-2301 * pnw.edu
Westville Campus
1401 S. U.S. Hwy 421 * Westville, IN 46391
(219) 785-5460 * pnw.edu
This section must be completed by both the employee and the employing department. By signing this form the
employee is certifying that all information provided on this form is correct and understands that falsification of any
information on this form may constitute fraud. The employee further certifies the relationship and dependency status
(if applicable) between the applicant and the employee, and agrees to furnish copies of federal income tax returns to
the University upon request. The staff member is to contact the Bursar office in the event of a change in family
status, termination or change in dependency status. The employing department is certifying the date of continuing
employment. Forward the form to Human Resources for final approval.
Required Signature of Employee:________________________________________________ Date:_________________________
Required Signature of Department Head:_________________________________________ Date:_________________________
I certify the employee listed above has been employed since _____\______\______ (If employment has not been continuous, it
should be noted.)
Signature: _________________________________________________ (Human Resources) Date: _________________________
Bursar Office Use Only: Date Entered_____________________ Initials____________________
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Hammond Campus
2200 169th Street * Hammond, IN 46323
(219) 989-2301 * pnw.edu
Westville Campus
1401 S. U.S. Hwy 421 * Westville, IN 46391
(219) 785-5460 * pnw.edu
BURSAR OFFICE
Staff Child And Staff Spouse Remission Policy
Please refer to Executive Memorandum No. C-7
• If a staff member’s appointment terminates within six weeks after the start of the semester or prior to July 1
during the summer session and course work is continued, full student fees must be paid for the semester or
summer session.
• If staff member is an Official Retiree of the University or disabled, they need to send the complete application
to Human Resources for verification.
• Remission will not cover any special fees, technology fees, lab fees, deposits, workshop fees and differential fees.
• Part-Time Lecturers and Visiting Scholars are not eligible for fee remissions.
Staff Child Remission
Staff Children Are: (1) Natural children, stepchildren, legally adopted children, or eligible foster children who
have not reached their 25th birthday prior to the term for which they will next enroll, who are unmarried and
are dependents of the employee as determined for federal income tax purposes with respect to the qualified
tuition reduction income exclusion or by a qualified child support order. Stepchildren and legally adopted
children must have had this status for at least one full year at the time of enrollment to be eligible for this
benefit. (2) Such children who have not received or completed requirements for a baccalaureate (or equal)
degree from a four year degree granting institution; and (3) such children who are eligible for admission and
retention under existing University policies.
• Parent or guardian is employed in a regular half-time or more position or an active duty member of the Armed
Forces with duties performed on a Purdue Campus or disabled and receiving short-term or long-term disability
benefits or retired or deceased and eligible to receive benefits as outlined in Executive Memorandum No.B-35.
• Student must be a full or part-time degree seeking undergraduate student.
• Student must not have earned a baccalaureate or professional degree from any institution.
• Student must be seeking a degree offered by the Northwest, West Lafayette or Fort Wayne campuses.
• Student must be under 26 years of age to initially obtain the remission.
• Students who are enrolled and turn 26 years of age will be eligible for the fee remission as long as they are
continuously registered.
Staff Spouse Remission
• The staff member must have been employed on a continuous basis for at least two years before the spouse is
eligible for the remission. (First day of the semester constitutes the cut off date.)
• The remission rate will apply for a maximum of seven (7) credit hours for Spring and Fall semesters and four (4)
credit hours for the Summer session. Full fees will be assessed on each hour over the limit.
Remission applies to undergraduate and graduate courses.
• The regular spouse fee remission does not apply to graduate staff; however, non-resident graduate staff
spouses are eligible for remission of non-resident tuition.
Note: Please make sure to obtain both the employee and department head signatures on this application.
Forms will not be processed without proper certification. Return the completed application form to
Human Resources.
Taxable Remission Information:
Under current Federal laws all or some portion of tuition remission benefits may be subject to income
or FICA taxes. It is the policy of Purdue University to comply with Federal and State laws requiring
the reporting of such income and withholding of such taxes. The University’s Human Resources
Service Center will deduct the required tax withholdings from the employee’s regular paycheck
during the semester period. An appropriate information return may be issued to an official retiree or
to the Qualifying Surviving Spouse/Dependent of a deceased employee.
Applicant* Enrollment Tax Implications
Regular Employee
applying for Staff
Remission
Undergraduate
Remission benefits are
not taxable
Graduate, or
Professional
Tax Benefits are taxable
per IRS regulations
after the first $5,250
Graduate Teaching or
Research Assistant
applying for Staff
Remission
Graduate, or
Professional
Remission benefits are
not taxable
Dependent Child
applying for Staff Child
Remission
Undergraduate
Remission benefits are
not taxable
Non-Dependent Child
applying for Staff Child
Remission
Undergraduate or
Professional
All remission benefits
are taxable
Spouse applying for
Staff Spouse Remission
or Qualifying Surviving
Spouse Remission
Undergraduate
Remission benefits are
not taxable
Graduate or
Professional
All remission benefits
are taxable
Surviving Child,
Dependent of
Staff/Official Retiree in
Year of Death, or both
Parents deceased and
under Age 25
Undergraduate
Remission benefits are
not taxable
Surviving Child, unless
Dependent of
Staff/Official Retiree in
Year of Death, or both
Parents deceased and
under age 25
Undergraduate or
Professional
All remission benefits
are taxable.
* For purposes above, any reference to Staff shall include an individual whose University status is
“official retiree”.
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Application for Staff Child or Staff Spouse Fee (Purdue University Northwest)

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Completed 16 August 2020

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