Fillable Dependent Fee Waiver Transfer Form Ready (California State University Channel Islands)

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Dependent Fee Waiver Transfer Form Ready (California State University Channel Islands)

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Dependent Fee Waiver Transfer Application
Term
Applying for: Semester Quarter Campus to Attend: ___________________________ Date: ___________
Fall Winter Spring Year: ___________ New or Continuing Student
Part I – EMPLOYEE INFORMATION
Employee Name:
Email:
Current Employee Status:
___Permanent
Circle one: FT PT (If PT – time base ______)
___Temporary FT; Appt. end date ___________
___On Educational Leave or approved leave of
Absence
____Staff ___Faculty
Employee ID #:
Job Classification:
Part 2 – DEPENDENT INFORMATION
Dependent Name:
Student ID#:
Relationship to Employee:
Date of Birth:
Email:
Receiving Financial Aid?
____ Yes ____ No
Applying for Admission?
_____ Yes _____ Already Admitted
Comments (if needed):
Part 3 – COURSE INFORMATION
Degree Objective:
___ Bachelor’s ___ Master’s ___ Credential ___Doctorate
How many courses does dependent intend to take? ______
How many units total? ______
___ Undergraduate Coursework
___ Graduate Coursework
Part 4 – EMPLOYEE VERIFICATION AND SIGNATURE
I understand that some courses taken through fee waiver may be subject to taxation. (Refer to IRC Tax Code Sections: 117(d); 127; and 132(d))
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 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.
Employee Signature:
Date:
Part 5 – OFFICE USE ONLY
Dependent is:
____ Eligible for Fee Waiver ___Not Eligible (Reason:_____________________________________)
Number of
Units:
Notes:
Phone:
Date:
Edited 1/27/17- jk
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Dependent Fee Waiver Transfer Form Ready (California State University Channel Islands)

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Completed 20 July 2020

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