Tuition Grant Revised 7-2016
Hampshire College
Application for Tuition Grant
Please print clearly, complete all information requested.
Employee Information
Employee Name ___________________________________________________________________________________
Home Address ____________________________________________________________________________________
Department ________________________________ Title _________________________________________________
Date of Hire:___________________ FTE: ________ Faculty Administrator Staff
Extension _____________ Home Telephone ( ) _________________
Dependent Information
Name _____________________________________________________________________________________
Home Address ______________________________________________________________________________
Relationship to employee: Son ___ Daughter ____ Date of Birth __ ______
College/University student will be attending __________________________________________________________
College/University address ________________________________________________________________________
Student will be enrolled in: Academic Year ________________ Fall _____ Spring _____
Procedures and Policy for Tuition Grant Benefit
Employee required to complete a separate application for each dependent for each semester. Along with the completed application
employees are required to supply;
a copy of the current bill
proof of the dependent’s age (i.e. driver’s license, birth certificate, when first applying)
official verification that the child is a dependent (copy of most recent tax return, once a year)
and at the end of each semester supply an Enrollment Certification for the prior semester
All items are necessary in processing the application in a timely manner. If dependent voluntarily withdraws from school and/or is
eligible for a refund, the Human Resources Office must be notified in order to determine what portion, if any, of the refund is to be
returned to Hampshire College.
The tuition grant is limited to four academic years, until the dependent earns a bachelor’s degree, or reaches age of twenty-five (25),
which ever occurs first.
Submitted by: _______________________________________________________ Date: ____________________
Employee’s Signature
The following information is completed by Human Resources
For the account of ________________________________________ _
(Student’s Name)
Amount of Grant _______________________ Mail Check To: _____________________________________
(up to $1000. per semester) (Employee’s Name)
Semester # _____ Copy of current bill Proof of age Proof of dependent status Enrollment certification
Business Office Use: DR 90-033001-62460
Certified by __________________________________ Date: ____________________