Social Security:
- -
Social Security*:
- -
Term and Year Units
(Example)
Fall 2007 3
____________________________________________ _________________
Signature of employee requesting fee waiver Date
EMPLOYEE’S EMPLOYMENT STATUS (See Technical Letter HR/Benefits 2008-15 for eligibility criteria):
This employee is: ___Faculty or ___Staff
Eligibility:
___ Dependent is eligible for fee waiver benefits
___ Dependent is not eligible to receive fee waiver benefits (Reason: _______________________________________________)
Number of Units Eligible for: ______Undergrad Units or ______Graduate Units (including Ed.D.)
Position # _______-_______-_______ CBID: _________
Additional Fees (e.g., extra unit fee, late fees) Total: _______________ Budget Code: ___________
Fee Waiver Coordinator Signature____________________________________________________ Date__________________
Fee Waiver Coordinator Campus:____________________________ Phone Number:_________________________________
DEPENDENT FEE WAIVER TRANSFER APPLICATION
CALIFORNIA STATE UNIVERSITY
CIN:
Phone Number:
Is the dependent applying for admission at this time?
___Yes ___No
Has the $55 application fee been paid? ___Yes ___No
Is the dependent receiving financial aid? ___Yes ___No
Student Status:
___New Student or ___Continuing Student
___Undergraduate ___Graduate ____Ed.D. ___Credential
Campus to attend ____________________
California Resident? ___Yes ___No
NOTE: Some courses taken through fee waiver may be subject to taxation.
*The Social Security number is required of those who wish to participate in the Dependent Fee Waiver program. The number will be used as
a common identifier for course enrollment and related purposes. Authority for such use is contained in Title 5 of the California Code of
Regulations.
Level (Undergraduate or Graduate)
Undergraduate
Mailing Address:
SECTION II – Dependent Information
SECTION 1 – Employee Information
Classification Title:
Time Base: ___Full time ___Part time
Status: __Permanent __Probationary __Temporary (appt. exp.____________)
Relationship to employee:
___Spouse by Marriage
___Dependent Child (Please specify by checking one of the below
choices) Note: CSUEU limit for child is 25
___ child or stepchild under age 23/25 who has never been
married
___ child living with employee in parent-child relationship who
is economically dependent upon employee, under age
23/25 who has never been married
___ child or stepchild age 23/25 or above who is incapable of
self-support due to a disability that existed prior to age
23/25
___ Domestic partner (Declaration of Domestic Partnership is filed
with the Secretary of State)
Name:
Email Address:
Course Title & Number
Art History 108
Name:
Date of Birth:
______/______/______ (Month/Day/Year)
OFFICE USE ONLY
I certify that the individual named above is my legal spouse, dependent child, or registered domestic partner and that the information provided
above is true. I wish to transfer my fee waiver eligibility, as provided in appropriate policy or collective bargaining understand this transfer
prohibits my personal use of fee waiver benefits during the period indicated. Further, I understand that my spouse, dependent child or
domestic partner is responsible for meeting all registration and payment deadlines and informing the Human Resource office if any changes in
approved fee waiver classes occur.
SECTION III – EMPLOYEE VERIFICATION AND SIGNATURE
Email Address:
Department:
Campus, Campus Address & Phone:
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