Fillable Tuition Fee Waiver Non LHU Student (Lock Haven University)

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Tuition Fee Waiver Non LHU Student (Lock Haven University)

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TUITION WAIVER FOR FACULTY, MANAGEMENT6&83$ AND COACH
WHO’S DEPENDENT ATTENDS OTHER STATE SYSTEM SCHOOLS
Please Note:
Tuition Waiver forms will not be approved more than eight (8) weeks before the start of the
semester for which the waiver is requested.
A separate form must be submitted for each semester. Forms requesting multiple semester
waivers will not be processed.
TO BE COMPLETED BY FACULTY/STAFF MEMBER:
Employment Type:
□ Manager □ Faculty
Employment Status: □ Active Employee □ Annuitant
Name: _____________________________________________________________________________
Name of Employing University:________________________________________________________
Name of Student:_____________________________________________________________________
Date of Birth:_____________________________ Relationship:_____________________________
Name of Attending University:_________________________________________________________
Semester/Year:_______________/______________
Employee/Annuitant Verification: I hereby certify that the above-named student qualifies as my
dependent in accordance with, and meets the qualification as defined by, the Board of Governor’s
Policy/APSCUF Collective Bargaining Agreement. I agree to provide the University proof of
relationship and age as may be required. I understand it is my responsibility to meet the deadlines for
tuition payment at the university attended by the student.
____________________________________________________________ ___________________
Employee/Annuitant Signature Date
(Guardian or Beneficiary may provide verification of relationship in even of Employee/Annuitant Death)
Return to Employing University’s Human Resources Department
University Use Only
HUMAN RESOURCES DEPARTMENT at employing University: The employee’s/annuitant’s
eligibility and student’s qualifications for the tuition waiver have been reviewed, and I hereby certify
that the information submitted is true and accurate to the best of my knowledge.
__________________________________________________________ ______________________
Signature and Title Date
FORWARED TO BUSINESS OFFICE at university attended by student
BUSINESS OFFICE must forward copies to other appropriate offices at attending university.
SCUPA
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Tuition Fee Waiver Non LHU Student (Lock Haven University)

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Completed 23 July 2020

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