Connecticut State Colleges & University System
Tuition Waiver (Full- and Part-time)
Taxable Income Notice: Undergraduate tuition benefits for the employee, spouse, and eligible dependents are tax- exempt. Graduate-
level tuition benefits are tax-exempt for the employee up to the IRS maximum for the calendar year. Graduate-level tuition benefits for
the spouse and eligible dependents are taxable to the employee. For more information, refer to the Graduate-Level Educational
Assistance Tax Reporting Requirements at http://www.ct.edu/hr/employee#benefits.
Part A (Applicant)
Name of Student:_________________________________ Employee Name:
Student ID #_____________________________________ Employee Title:
State ID #:
Work Address:
Work Phone:
Campus to be attended: C E S W
Student is: Full-Time Graduate*
(See above and back) Location of Employment:
Part-Time Undergraduate C E S W System Office
Has student attained Bachelor’s degree? Yes No
Unit Membership:
Semester requested 20_____
Fall Intersession
Spring Summer A/I B/II C/III D/IV
Spring Break
AAUP Part-time number of load credits against which this
waiver is sought ___________ .**
Relation of Student to Employee
Semester of employment being credited
Self Spouse Child
Fall Winter Spring Summer Year 20
Age of Child _________D.O.B. ________________
(**The total benefit shall not exceed the member’s current equivalent workload credit
and shall only be used during the semester of employment of the semester immediately
following.
(Eligible child is a natural, adopted or step-child who is unmarried
and under the age of 25.)
Employee Agreement: I certify that the above statements are true and that I understand that an approved Tuition Waiver Form represents
payment to the Connecticute State University school of attendance and should be submitted by the student to the Bursar/Cashier/Student
Accounts Office by the billing due date in order to avoid holds, late fees, and/or dropping of registrations. Late submissions of Tuition
Waiver Forms will not be accepted after the last day of classes and the student will be responsible for the full cost of tuition and fees.
Employee Signature______________________________________________________ Date______________
Part B (Human Resources Office of Employees' Primary Agency)
Employee is eligible for benefit **______/12 (Fraction to be waived if employee is part-time AAUP - # of load credits / 12 )
Application is rejected and returned to employee.
Reason:_________________________________________________
Application is approved on a space available basis
____________________________________________
_____________________________
CCC Human Resource Director / CSU Chief Human Resources Officer or Designee
________
_______
Date
Emeritus; Bargaining
Unit _______
AAUP
Management/Confidential
SUOAF-AFSCME
Community College Full Time (
4Cs/AFT/AFSCME)
Community College Part Time (4Cs/AFT/AFSCME)
CCC
GWCC
ACC
HCC MCC
NCC QVCC
TRCC
MXCC NVCC
NWCC
TXCC
Part C (Bursar / Student Accounts Office / Cashier's Office)
Number of credit hours:_______
Community College Approved Cash Value = $________
(Not to exceed $2238/semester for full-time employees AND $599/
semester for part-time employees)
This is to certify that the Bursar, Student Account Office, or Cashier's Office has processed this Tuition Waiver Form in accordance with
established guidelines.
Bursar/Student Accounts/Cashier's Signature_______________________________ Date______________
