Revised 7/10
Fee Waiver Application - Dependent
EMPLOYEE INFORMATION (to be completed by employee for each term of enrollment)
Contact Information:
Campus Address:
Campus Phone:
Fax:
Current Educational Level:
Freshman Sophomore Junior Senior
Graduate
Time Base: Full-Time Part-Time
Status: Permanent Probationary Temporary (appt, exp.____________)
Relationship to employee:
Spouse
Registered Domestic Partner
Dependent Child
Child or stepchild under age 23 who has never been married
Child living with employee in parent-child relationship who is
economically dependent upon employee, under age 23 and
who has never been married
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 Credential
COURSES TO BE CONSIDERED FOR FEE WAIVER:
Course Level (Undergrad/Grad)
Note: Some courses taken through fee waiver may be subject to taxation.
*The Social Security Number is required for 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.
EMPLOYEE VERIFICATION AND SIGNATURE
I certify that the individual named above is my legal spouse, registered domestic partner, or dependent child and that the information provided above is true. I
wish to transfer my fee waiver eligibility, as provided in the 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, domestic partner, or child is
responsible for meeting all registration and payment deadlines and for informing the CSUM Human Resources office if any changes in the approved fee waiver
classes occur.
_________________________________________________________________ ___________________________________
Employee’s Signature Date
HUMAN RESOURCES OFFICE USE
This employee is Faculty Staff FLSA Status: Exempt Non-Exempt
Eligible for Fee Waiver Yes No (Reason for not eligibile) ________________________________________________
Number of units eligible for: ______ Undergrad units _____ Graduate Units Courses are Career Development or Work-related
Position #______________________________ CBID _______________________
Additional Fees (e.g., extra unit fee, late fees) Total _________________ Budget Code: ________________
CSUM Fee Waiver Coordinator: __________________________________________________________ Date: _______________________
Attending Campus Fee Waiver Coordinator:_________________________________________________ Date:________________________
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signature
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