Fillable Dependent Fee Waiver Application Fillable

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Dependent Fee Waiver Application Fillable

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DEPENDENT
FEE WAIVER APPLICATION
SECTION 1 – Employee Information (to be completed by employee for each term of enrollment)
Name:
Fresno State ID :
Classification Title:
Department:
Phone:
SECTION II – Dependent Information
Name:
Campus ID :
Email Address:
Relationship to Employee:
Term and Year
Course Title & Number
Level (Undergraduate or Graduate)
Units
(Example) Fall 2017
Art History 108
Undergraduate
3
Student Account Services
Code / Amount ________________
HR Rep. Initials ________________
________________
E-mail Address:
Doctorate
Academic Program:
Graduate C
redential
CSU Campus to Attend: ___________________
Student Status:
New Student or Continuing Student
• REQUIRED* Students Attending Fresno State (for this campus only) - Submit confirmation of enrollment listing
the courses and units per course
• Students participating in this
program must be in good academic standing as defined by the Student Affairs
University Advising Center (‘Good Academic Standing’ does not include Probation, Disqualification, Contract status
or Administrative Approved Academic Probation). Academic standing will be reviewed each semester to determine
eligibility to participate in the subsequent semester.
• Some graduate/doctorate level courses taken through fee waiver may be subject to taxation.
• Non-California Residents are subject to out-of-state tuition/fees
• Fee Waiver does not apply to courses taken through Open University or Extended Education
Bargaining Unit:
UAPD* (Unit 1)
SETC* (Unit 6)
APC* (Unit 4)
M80/M98* (MPP/Executive)
CFA* (Unit 3)
Confidential (C99)
CSUEU* (Units 2,5,7,9)
SUPA (Unit 8)
Status: Permanent
Probationary
Temporary*(appt. exp.__________)
Time
Base:
Full time
Part time
Spring Summer CSU Summer Arts
Academic Year 20_______ Term:
Fall
Spouse by Marriage
Domestic Partner (Declaration of Domestic Partnership is filed with the Secretary of State)
Child or stepchild under age 23/25
Child living with employee in parent-child relationship who is economically dependent upon employee, under age 23/25
Child or stepchild age 23/25 or above who is incapable of self-support due to a disability that existed prior t
o age 23/25
Human Resources, Joyal Administration Building, Room 211, (559) 278-2032
Page 1 of 2
Rev. 7/2018
Depen
dent Child (who has never been married)
Date of Birth ________________ (mm/dd/yyyy)
NOTE: (For Physicians/Unit 1 and Public Safety/Unit 8 employees, age limit is 23)
Must Select One
:
Major: _________________________________
Undergraduate
SECTION III – NOTE: THE FOLLOWING APPLIES TO THE FEE WAIVER PROGRAM
REQUIRED* For Non-Fresno State Students Only (Students Attending Other CSU Campus complete section below)
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SECTION III – EMPLOYEE VERIFICATION AND SIGNATURE
I certify that the individual named above is my legal spouse, dependent child, or registered domestic partner
(Dependent) and that the information provided above is true. I wish to transfer my fee waiver eligibility, as provided in
appropriate policy or collective bargaining agreement, to the individual named above. I 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.
Students participating in this program must be in good academic standing. Academic standing will be reviewed each
semester to determine eligibility to participate in the subsequent semester. ‘Good Academic Standing’ does not include
Probation, Disqualification, Contract status or Administrative Approved Academic Probation.
For information on Academic Probation: http://www.csufresno.edu/studentaffairs/programs/advising/disquali.shtml
If my Dependent is attending CSU, Fresno, a confirmation of enrollment listing the courses and the units per course is
attached to my application. Applications will be considered incomplete and will be returned if this information is
not attached.
I understand that fees waived on behalf of an employee’s legal spouse, dependent child, or registered domestic partner
for enrollment in graduate-level courses may be reported as taxable income for the employee. All
undergraduate level course work taken by an employee’s domestic partner through this program is taxable as well.
All fees should be paid directly to the cashier in the Joyal Administration Building. If there are any questions regarding E-
pay or other payment options, please contact Students Accounts at (559)278-2876.
Student may contact the Admissions office at (559)278-2261 (Undergrad Admission) or (559)278-4072 (Grad Admission)
to request a one time reimbursement of the CSU Application Fee ($55).
I UNDERSTAND THAT THE STUDENT MAY ALSO BE CHARGED FULL OR PRORATED REGISTRATION FEES IF
THE STUDENT DROPS CLASSES FOR WHICH THE STUDENT HAS BEEN GRANTED A FEE WAIVER. THE
WAIVER WILL BE REMOVED AND FEES WILL BE CHARGED UP TO THE FULL AMOUNT AS OF THE DATE OF
THE CLASS WITHDRAWAL. See Accounting Services web page for more information.
As an employee, I have read and understand the conditions of the Fee Waiver Program which can be found on the
Technical Letter HR Benefits 2011-14 and my Collective Bargaining Agreement.
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DEPENDENT FEE WAIVER APPLICATION
Human Resources, Joyal Administration Building
Room 211, (559) 278-2032
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Completed 19 April 2020

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