Fillable Tuition Remission Qual Relative Feb2017 (California Lutheran University)

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Tuition Remission Qual Relative Feb2017 (California Lutheran University)

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Application for Tuition Remission
Qualifying Relative
Submit this form and Proof of Relationship*
Please complete entire form and return to the HR Department at least two weeks in advance of each semester or term. Incomplete forms will not be accepted.
DEPENDENT STUDENT INFORMATION
STUDENT’S LAST NAME
FIRST NAME
MIDDLE INITIAL
DATE OF BIRTH
CLU ID #
STUDENT’S STREET ADDRESS
STATE
ZIP
STUDENT’S EMAIL
CONTACT PHONE
STUDENT’S RELATIONSHIP TO EMPLOYEE*
IS STUDENT MARRIED?
IF SO, DATE OF MARRIAGE
*Acceptable proof of relationship includes marriage certificate, birth certificate, etc. For additional reference please refer to the Employee Handbook.
APPLICATION INFORMATION
ANSWER ALL THAT APPLY TO THIS APPLICATION
Yes No
Are you seeking your first Baccalaureate degree?
Yes No
Are you a regularly admitted student for the Undergraduate program?
PLEASE INDICATE WHICH PROGRAM YOU WILL ENROLL IN THIS TERM
Traditional Undergraduate program (semester based) with fewer than 150 CLU units to date
Bachelor’s Degree for Professionals program (quarter based) with fewer than 150 CLU units to date
Fifth-year Credential program with fewer than 36 attempted units to date
PLEASE INDICATE YOUR REGISTRATION DETAILS FOR THIS APPLICATION
FALL
WINTER
SPRING
SUMMER
ACADEMIC YEAR:
TOTAL UNITS:
PLEASE INDICATE YOUR CLASS STANDING FOR THIS TERM CHECKED ABOVE
FRESHMAN (0-29 UNITS)
SOPHOMORE (30-59 UNITS)
JUNIOR (60-89 UNITS)
SENIOR (90-124 UNITS)
5
TH
YEAR CREDITIAL
EMPLOYEE INFORMATION
EMPLOYEE’S LAST NAME
EMPLOYEE’S FIRST NAME
EMPLOYEE’S HIRE DATE
EMPLOYEE’S CLU ID #
EMPLOYEE’S DEPARTMENT / WORK EXTENSION
EMPLOYEE’S HOME PHONE
SIGNATURE
To the best of my knowledge, I certify that the above information is true and correct.
I have attached or have on file with Human Resources proof of relationship, including a copy of the Tax Return for parent of dependent child.
SIGNATURE OF QUALIFIED RELATIVE
DATE
SIGNATURE OF EMPLOYEE
DATE
Taxation of benefits offered under the Education Benefits Policy is determined by the Internal Revenue Code and is subject to change at any time.
For additional reference, please refer to the Education Benefits policy.
For HR office use only:
Eligible
Ineligible
FTE Status
Payroll Hours
Benefit
class(es) at
%
Tax Return Verified
HR Benefit Initials
AVP of Human Resources Signature
Date
Human Resources Department - 60 W Olsen Road #1100 - Thousand Oaks, CA 91360 - P: 805.493.3185 – F: 805.493.3655 Feb 2017
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Tuition Remission Qual Relative Feb2017 (California Lutheran University)

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Completed 20 July 2020

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