Fillable Form RV Towson University Maryland request for tuition remission form

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Form RV Towson University Maryland request for tuition remission form

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USM REQUEST FOR TUITION REMISSION
Each USM Employee or Retiree seeking tuition remission for self, a spouse or child shall complete this application and
accompanying certification to provide the information necessary to comply with both the USM-BOR Tuition Remission policies (VII-
4.10; VII-4.20) and Internal Revenue Service regulations regarding the income tax law status of the tuition remission benefit requested by
the employee. This page provides the information necessary to ascertain eligibility and process the request; additionally the
employee/retiree is also required to complete and sign the Affidavit for tax status of the tuition remission recipient.
Upon obtaining departmental authorization, the employee/retiree must present this request to the employing Institution Human
Resources Office for approval. A new request must be completed for each semester/session. If the student is registering at multiple
Institutions, a separate request must be completed for each Institution.
1. Calendar Year: 20_____
Semester for which tuition remission is requested (enrollment term) □ Fall □ Winter □ Spring □ Summer ____
(include summer session # if institution has more than one Summer Session) □ Other ____________________
2. Employee Name:
(Last Name, First Name)
10. Student Name (Spouse/Child):
(Last Name, First Name)
3. Employee SSN:
11. Student SSN (Spouse/Child):
4.
Employee Date of Hire:
Month/Day/Year ____/____/____
Do you have prior USM Service/dates? Yes _____ No __
12. Student is Employee's:
□ Spouse □ Child
5. Complete if employee is retired or deceased:
Month/Day/Year
□ Retired ____/____/_____
□
Deceased ____/____
/
_____
13. Student's Date of Birth:
(Required for a child - if employee or
spouse of employee, leave blank)
Month/Day/Year ____/____/____
6. Active Employee is Employed: □
Full time
□
Part time
Enter % employed if less than full time ______________%
Retired or deceased employee was employed:
□
Full time □ Part time
Enter % employed if less than full time ______________%
14. Student Enrollment Status:
□ Undergraduate □ Freshman □ Sophomore
□ Junior □ Senior
□ Graduate
7. Employee Status:
□ Nonexempt □ Contingent Catg. II □ Grad. Asst.
□ Exempt □ Retiree □ Grad. Research Asst.
□
Faculty
□
Fellow
□
Grad. Teaching Asst.
8. Employee’s Home Institution:
□ BCCC □ BSU □ CSU □ FSU □ MIANR-
AES
□ MIANR-UME/CES □ MSU □ SU □ SMCM
□ TU □ UB □ UMB □ UMB-MIEMSS
□ UMBC □ UMBI □ UMCES □ UMCP □ UMES
□
UMUC
□
USMO
15. Institution where employee/student is registered:
□ BCCC □ BSU □ CSU □ FSU □ MSU
□ SU □ SMCM □ TU □ UB □ UMB
□ UMBC □ UMCP □ UMES □ UMUC
□ For Grad Assistants: Check box if your course is held at a different Institution
from where you registered for the course (ie: an inter-institutional course).
9. Employee’s Institution Work Address:
___________________________________________
Employee’s Work Phone #: __________________
Employee’s Institution E-mail Address:
_________________________________________
16. Number of credit hours to be remitted: ________
List account number(s) from which employee is paid:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
17. Institution transfer of funds: Yes___ No___ ; %___
(To be completed by Institution HR Benefits Coordinator)
Please continue on to the TR Affidavit - complete and sign. This TR Request shall not be processed
without the completed and signed TR Affidavit.
USM Form-RV – Revised 11-12-2014
USM REQUEST FOR TUITION REMISSION – AFFIDAVIT (A)
TAXABILITY FOR SELF, SPOUSE OR CHILD
E
MPLOYEE/RETIREE NAME:_________________________ CHILD/SPOUSE NAME:______________________
This affidavit must be completed by all employees and retirees requesting TUITION REMISSION (TR) to determine
whether the Institution must treat the requested TR as taxable income to the employee or retiree under the Internal
Revenue Code. In most cases, TR is not taxable for undergraduate courses taken by an employee, retiree, spouse or
child who qualifies as the employee’s dependent under federal tax law standards. In addition, specific IRS rules govern
the taxability of TR for graduate education and children of divorced and separated parents. Those rules are summarized
on a Tax Chart on the USM’s Website at:
http://www.usmd.edu/usm/adminfinance/tuitiontax.pdf.
This affidavit is necessary to comply with federal tax law and to protect you and the USM Institution from potential
tax liabilities and penalties. To complete the affidavit, read the statements below and follow the instructions
.
1. UNDERGRADUATE TUITION REMISSION FOR A SPOUSE - If you are seeking TR for your spouse, initial
statement below:
____ I certify that the person for whom I am requesting TR: (a) is my spouse and that we have entered a legally
effective marriage, and (b) that we are not estranged, and that he/she does not maintain a separate domicile.
2. UNDERGRADUATE TUITION REMISSION FOR A CHILD – Initial ONE applicable statement below:
a. If you are seeking undergraduate TR for a child whom you will claim as a dependent on your federal income
tax return for the year 20___, initial the following:
____ I certify that the person for whom I am requesting TR is my biological child, stepchild or legally adopted child and
that I intend to claim the child as my dependent on my federal income tax return for the 20
___ calendar year. If I
do not claim my child as a dependent on my income tax return for the 20
___ calendar year as indicated above, I
will notify my HR Office as soon as possible and no later than 15 days of filing my tax return, and I understand
that the value of my child’s TR will be considered taxable income to me.
b. If you are seeking undergraduate TR for a child whom you will NOT claim as a dependent on your federal
income tax return for the year 20___, initial ONE applicable statement:
____ (i) Although I do not intend to declare my biological child or legally adopted child as a dependent on my federal
income tax return for the 20
___ calendar year, (a) I am currently divorced or separated from the child’s other
parent, (b) the child’s other parent will claim the child as a dependent on his/her federal income tax return for the
20_
__ calendar year, and (c) my marriage to the other parent is or was recognized under federal law. If the child’s
other parent does not claim my child as a dependent for this tax year, I will notify my HR Office as soon as
possible and no later than 15 days of the filing of the tax return of the child’s other parent, and I understand that
the value of my child’s TR will be considered taxable income to me.
____ (ii) Although I do not intend to declare my stepchild as a dependent on my federal income tax return for the 20___
calendar year, either (a) my spouse will declare my stepchild as a dependent on his/her tax return for the 20
___
calendar year, OR (b.1) my spouse is divorced from my stepchild’s other legal parent, (b.2) my stepchild’s other
legal parent will claim the child as a dependent on his/her federal income tax return for the 20_
__ calendar year,
AND (3) my marriage to my spouse, who is a legal parent to my stepchild for whom I am seeking tuition
remission, is recognized under federal law. If neither my spouse nor my stepchild’s other legal parent claims my
stepchild as a dependent for the 20
___ calendar year, I will notify my HR Office as soon as possible and no later
than 15 days after both my spouse and my stepchild’s other legal parent have filed their 20
___ calendar year tax
returns, and I understand that the value of my stepchild’s TR will be considered taxable income to me.
____ (iii) I certify that the person for whom I am requesting TR (a) is my biological child, stepchild or legally adopted
child, and (b) I do not intend to declare this child as a dependent on my federal income tax return for the 20
___
calendar year, (c) neither 2.b(i) or (ii) apply, and (d) I understand that the value of my child’s TR will be
considered taxable income to me.
TR AFFIDAVIT (A) - Page 1
3. TUITION REMISSION FOR GRADUATE EDUCATION - If you are seeking TR for graduate education for
yourself or a family member, initial ONE applicable statement:
____ I am applying for TR for my own education in courses at the graduate level, and the courses qualify as a “working
condition fringe benefit,” which means: the courses are required by law or the Institution for me to keep my
present job OR maintain or improve skills required for my current employment, AND the courses will not qualify
for the minimum educational requirements for my current position, AND the courses will not qualify me for a new
trade or business.
____ I am applying for TR for my own education in courses at the graduate level which do not qualify as a “working
condition fringe benefit” as that term is used in the Internal Revenue Code, and I understand that I will be taxed
for the value of the TR that may exceed $5,250.
____ I am applying for TR for the education of my spouse or child or stepchild in courses at the graduate level, and I
understand that I will be taxed for the full value of the TR.
4. GENERAL ACKNOWLEDGEMENTS - All applicants must INITIAL EACH APPLICABLE statement
below:
I understand that the following requirements are applicable to my application for and receipt of Tuition Remission:
____ a. I have read and I understand the relevant USM-BOR TR policies (VII-4.10 and VII-4.20), which appear at
http://www.usmd.edu/regents/bylaws/SectionVII/ and the USM Tuition Remission–Deadlines And Restrictions
Chart, which appears at:
Tuition Remission Deadlines and Restrictions Chart
____ b. To the extent that any TR is taxable income under IRS regulations, the value of the TR will be added to an
employee’s salary for taxation over designated pay periods during the semester when TR is used, according to the
schedule set by the State Central Payroll Bureau, OR reported as taxable income to a retiree.
____ c. If I am applying for Tuition Remission as a USM retiree, I understand that I must be, and affirm that I
am, receiving a retirement periodic distribution from either the State Retirement System or from the
Maryland Optional Retirement Program (ORP) during the period of time I am using Tuition Remission.
____ d. I understand that the Institution where student registers for courses has final approval authority for my TR
request.
5. I HEREBY SOLEMNLY AFFIRM UNDER PENALTIES OF PERJURY THAT:
a. The information I have given above is true and accurate;
b. I understand that willful falsification of information in this Affidavit can result in referral for investigation and
prosecution, full disciplinary action by the Institution, and civil action by the Institution to recover any costs that it
may incur because of such a false statement;
c. For compliance and audit purposes, I agree to provide to the Institution a copy of any documentation (including
relevant birth certificates, marriage licenses and
tax returns) that the HR Office deems necessary to ascertain
eligibility or the taxability of tuition remission. I understand that failure to timely provide all requested
information will result in the Institution denial of benefits or treating the value of the TR as taxable income to me.
d. I understand that I must notify the HR Office in writing
no later than 15 days of my first becoming aware of any
change in the information that I have provided in this Affidavit and as a result, I understand that the value of the
TR may be taxable income to me and applied retroactively to the appropriate taxable year. I further understand
that failure to notify the Institution of any changes may be considered willful falsification, to be treated as
described in item b. of this section.
Signature of Employee/Retiree:___________________________________________________________ Date: ___________
Signature of Department Head/Designee: ___________________________________________________ Date: ___________
Signature of Human Resources Representative at Employing Institution: ________________________ Date: ___________
TR AFFIDAVIT (A) - Page 2
USM Form – RV – Revised 11-12-2014
TAX CHART-A – USM TUITION REMISSION
Eligibility for tuition benefits must be determined under USM-Board of Regents Policies VII-4.10 and VII-4.20. This chart
provides a general overview of the taxability of various types of tuition remission. It does not constitute tax advice.
Each employee or recipient of tuition remission is strongly encouraged to discuss all questions related to tax liability with
his or her accountant or tax advisor.
Who is the Student? Undergrad
or Graduate?
Taxable or
Not Taxable
for federal
income tax
purposes
Special Notes
1.
Employee/Retiree Undergraduate
(all courses)
Not Taxable
2. Employee (does not include Retiree) Graduate
(work related)
Not Taxable
(see note)
Graduate: MUST qualify as a
working condition fringe
benefit, not to meet minimum
job qualifications or qualify for
a new trade or business as
defined in Affidavit-A, Section 3
3. Employee/Retiree Graduate (not
work related)
First $5,250 is
Not-Taxable.
Any amount
over $5,250 is
TAXABLE
4. Spouse, Widow/er, or Child of Employee/Retiree* Graduate TAXABLE
5. Spouse or widow/er of Employee/Retiree Undergraduate Not-Taxable ”Spouse” means a spouse who
would be recognized as such
for federal tax purposes.
6. Federal tax dependent who is Employee’s/Retiree’s*:
• Son/Daughter
• Stepson/Stepdaughter
• Legally adopted Son/Daughter
Undergraduate Not-Taxable
Employee/Retiree (regardless
of marital status) must claim
the student as a dependent on
the employee’s federal tax
return for the year in which
tuition remission is granted,
unless row 7 is applicable.
7. Employee’s/ Retiree’s*:
• Son/Daughter
• Stepson/Stepdaughter
• Legally adopted Son/Daughter
If Employee/Retiree (or the Employee/Retiree’s
spouse, in the case of a stepchild) is
divorced/separated from child’s other parent who
claims child as a tax dependent
Undergraduate
Not-Taxable
Unless
the employee/retiree, OR
the employee/retiree’s spouse, OR
the other parent of the
employee/retiree’s child/
stepchild claims the student as a
dependent on his/her federal tax
return for the year in which tuition
remission is granted to the
employee/retiree,
the tuition
remission will be taxable.
8. Employee’s/Retiree’s* Son/Daughter;
Stepson/Stepdaughter; or Legally adopted Son/Daughter
Who is NOT A TAX DEPENDENT of Employee/Retiree
AND
who does not fall within row 7 for the year
benefits are received
Either
Undergraduate
or Graduate
TAXABLE ALL tuition remission for a child
of any age not claimed as the
employee’s/retiree’s tax
dependent is taxable, except
for a child of divorced or
separated parents who is
described in row 7.
* Includes a deceased employee or deceased retiree
Note: This chart and Tuition Remission Policies VII-4.10 and VII-4.20 DO NOT apply to Graduate Assistants.
USMO-RV - Revised 11/12/2014
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