Fillable Tuition Waiver Form

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Tuition Waiver Form

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Lock Haven University of Pennsylvania
Tuition Waiver
SECTION I (To
be c
o
mpleted in its entirety by student
a
nd
/
o
y
ee
a
f
ter
v
erif
y
ing eli
g
ibility. Quest
i
o
ns rel
a
ting
to
eligibility should be
direct
e
d to
the B
e
nefits staff in the
Hu
m
a
n
Resources D
e
pa
r
t
m
ent.
Please Note:
?
T
u
iti
o
n
W
a
i
v
er f
o
r
m
s will
no
t
b
e ap
p
r
o
v
ed
m
o
re t
h
an
e
i
g
h
t (8)
w
eeks
b
ef
o
re t
h
e start of
t
h
e se
m
ester for w
h
ich
t
h
e wai
v
er is
r
eq
u
ested.
?
A s
e
parate
form
m
u
st be submitted for
each se
m
ester.
For
m
s
requesting
m
u
ltiple s
e
m
ester wa
i
v
ers
wi
l
l not
be
proce
s
sed.
?
Ap
p
licati
on
s
m
u
st
b
e s
ub
m
itt
e
d
p
r
i
o
r
t
o
t
h
e be
g
i
n
n
ing
o
f each
ter
m
.
?
Ap
p
licati
on
s
f
i
led
after t
h
e co
m
p
l
e
ti
o
n
date
o
f t
h
e co
u
rse(s) will
no
t
b
e co
n
si
d
ered.
Student
'
s
Name:
S
o
c
i
a
l Security # (new
student):
S
t
uden
t
I
D #
(re
t
urnin
g
s
t
udent
)
:
D
at
e
o
f
Bir
t
h
:
Semeste
r
: (Please
c
heck
on
e
)
Fall 20
Spring 20
Summer I 20
Summer II 20
Extended Summer 20
Total Cre
d
it H
o
urs
Enr
o
lled
(Please r
e
fer
e
n
c
e ap
p
lica
b
le t
u
i
ti
o
n wai
v
er
po
l
icy f
o
r e
m
p
l
o
y
ee wai
v
er li
m
it
s)
Re
la
t
i
o
n
s
h
i
p
t
o the
LH
U
em
p
l
oy
ee
(
Che
c
k
o
n
e
):
Self*
Spo
u
se
C
h
ild
Domestic Partner
A
g
e at b
e
g
i
n
n
i
n
g of
se
m
ester
(
f
o
r c
h
ildren of e
m
p
l
o
y
ees
on
l
y):
Alre
a
d
y h
a
ve
u
nd
er
g
r
a
duate
d
egree
f
rom
L
H
U or o
t
her
u
n
i
v
ersit
y
/college:
Yes
N
o
C
o
u
rse
L
e
vel
t
o be
t
ak
e
n:
Un
de
r
g
r
ad
u
a
t
e
Gr
adua
t
e
(
Wa
i
v
e
r
f
o
r
C
o
a
c
hes
&
Facu
lt
y
o
n
l
y
n
o
t d
e
p
e
nd
e
n
t
s)
If self:
*
Have accu
m
ulated 128
or
m
ore cre
d
its from
LHU:
Y
e
s
No
*
T
u
ition wai
v
er limited
to
6 s
h
.
p
e
r aca
d
e
m
i
c term
and all summer
semester
except for faculty and
coaches
E
m
p
l
o
y
ee's N
a
m
e:
Tele
p
ho
n
e
N
u
m
b
e
r
:
E
m
p
l
o
y
ee C
o
st Ce
n
ter:
Stat
u
s:
A
cti
v
e
Reti
r
ee
Che
c
k
One
(To
b
e
c
o
m
plet
e
d
by
e
m
ployee
)
:
(
Note
: AFSC
M
E, SCUPA
& SPFPA e
m
p
lo
y
ees must have
or will complete
their
six month probationary period by
the l
a
st day
of drop/
a
dd p
e
rio
d
.)
AFS
C
ME
(see
note
above)
APS
C
UF
(Fa
c
ulty)
SPF
P
A
(see
n
o
te
a
b
ov
e
)
M
anage
m
ent
SCU
P
A
Non
-
fa
c
u
lty
Athletic
Coach
I
certi
f
y
that
all
of
the
informa
t
ion
listed
above
is
accurate
and I
understand
that it
may
be
subject
to
audit. Failure
to
p
r
ovi
d
e
c
omple
t
e
and
accurate
information
may result in
deni
a
l of
the
benefit
and/or
d
isciplinary
acti
on
.
Student's Signature:
Date:
Employee's Signature:
Date:
SECTION II
(To be
co
m
pleted by
Hu
m
a
n
Resources
R
e
presentative)
A
p
p
ro
v
in
g
Sig
n
atu
r
e
:
Date
:
Wa
i
v
e
r
Pe
rc
enta
g
e:
Winter Intersession 20
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Tuition Waiver Form

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Completed 3 March 2020

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