Tuition Remission Revised 7-2016
Hampshire College
Application for Tuition Remission
Please print clearly and complete all information requested.
Employee Information
Employee Name_______________________________________________________________________________
Home Address ________________________________________________________________________________
Department ________________________________ Title _____________________________________________
Date of Hire:___________________ FTE: ________ Faculty Administrator Staff
Extension _____________ Home Telephone ( ) _________________
Student Information
Student Name __________________________________________________________________
Home Address _________________________________________________________________
Relationship to employee: Son _____ Daughter _______
Date of Birth ______________ Marital Status ________
Student will be enrolled in: Academic Year: _________ Fall _____ Spring _____
Procedures and Policy for Tuition Remission Benefit
Employee must submit the following items to insure processing:
application for tuition remission
supply proof of the dependent’s age (i.e. driver’s license, birth certificate, when first applying)
supply official verification that the child is a dependent (copy of most recent tax return, provided once a year)
I have reviewed and understand the Tuition Remission Policy as stated in the Hampshire College Policy
Manual, and have discussed any questions regarding this policy with Human Resources.
Submitted by: _______________________________________________________ Date: ____________________
Employee’s Signature
Human Resources Certification
Semester # _______ Proof of age Proof of dependent status
General Ledger 90-033001-62461 FTE: _______
Certified by __________________________________ Date: ____________________
Business Office Certification
Fall Semester Total Tuition Remission Allowed $_________________ @ _____ FTE
Spring Semester Total Tuition Remission Allowed $_______________ @ _____ FTE
Certified by: ______________________________________________ Date: _______________