Fill - Free fillable Hudson Valley Community College Tuition Reimbursement Application PDF form

TUITIONREIMBURSEMENTAPPLICATION

FORCHILDRENORSPOUSEOFNON‐TEACHINGPROFESSIONAL(EXEMPT)

CALENDARYEAR________

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1.Semesterandyearforwhichyouareregisteri ng tuitionassistance:

Spring_____Summer_____Fall_____(Fillinyearandcircle)

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2.NameofStudent_______________________________ _________________________

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3.StudentSocialSecurityNumber:_____________ _________________

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4.EmployeeName:________________________________________________________

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5.Numberofmatriculatedcredithoursregistered:

Spring________;Summer________;Fall________;Intersession________

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6.Nettuitionandacademicfees(lab/computer)balancebysemester:

Spring________;Summer________;Fall________;Intersession________

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7.Didyoucompleteafederalfinancialaidapplication“FreeApplicationforFederalStudentAid”?

Yes_________No________

WereyouawardedPELL/SEOG? Yes_________No________

Spring________;Summer________;Fall________;Intersession________

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8.DidyoucompleteandfiletherequiredstateformsandfiletodetermineyourTAPeligibilityorpart‐timeaid

eligibility?Yes_________No________

WereyouawardedTAP? Yes_________No________

Spring________;Summer________;Fall________;Intersession________

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9.DidyoucompleteandfiletherequiredCollegeformsandfileforHVCCscholarships?

Yes_________No________

Scholarshipawardreceived(calendaryear________):

 Scholarshipname__________________________________________

 Amount:$____________

 Scholarshipname__________________________________________

 Amount:$____________

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10.Whencompletingyourfederal/statetaxreturnforcalendaryear______,didyoureceiveacreditfortuitionthat

wasdeductedfromyourfederal/statetaxliability?Yes________No________AMOUNTOFCREDIT?$________

Ifno,wasitbecauseyouwerenoteligibleforthecredit?Yes________No________

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DEADLINEDATEFORCOMPLETIONOFTUITIONREIMBURSEMENTAPPLICATIONFORM:MAY1

OFTHEYEAR

FOLLOWINGTHESEMESTERTOBECLAIMEDFORREIMBURSEMENT

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Iaffirmunderpenaltyofperjurythat_______________________________________ismyson/daughter/spouseandby

mysignature,Ialsoaffirmthatallinformation Ihaveprovidedonthisapplicationformistrueandcorrect.



__________________________________________________________________________

EmployeeSignatureDate



OfficeUseOnly:Nettuitionbalancecalculation

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Hudson Valley Community College Tuition Reimbursement Application

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