University of Arkansas at Little Rock
Spouse/Dependent Tuition Discount Form
Undergraduate Courses Only
Instructions: Complete this form, print, sign, and send it to the Provost’s Office (ADS 311) or fax to (501) 683-7082.
Deadlines and additional information about tuition discount at UALR are found at the following
Student Name Student ID Date
Relationship to employee: Spouse Dependent (If dependent, please provide date of birth.)
Employee Name Employee ID Employer (Home Campus)
Employee Email Address Phone Number
Per IRS regulations, dependents cannot be 24 years old or turn 24 years old at anytime during the calendar year you are requesting the tuition
discount. Certain exceptions may apply if your dependent is over 24. Please refer to the IRS regulations for those exceptions.
Total Undergraduate Hours Completed to
Major/Program Select Degree Sought from Dropdown list Date1
Select Term from the Dropdown list below Academic Year (2011, 2012, etc.) Campus Attending (UALR, UAF)
By signing below, I certify that I am eligible under existing university policy for the tuition discount requested.
Student Signature Date
I certify that the above student is my spouse or dependent child as defined by the Internal Revenue Service. A dependent child per the IRS is a
full-time student under the age of 24 at the end of the year or if the student is permanently or totally disabled. I agree to furnish documentation
in support of the validity of the above statements, including, if requested, copies of Federal and State Income Tax returns as may be necessary to
confirm my claim of dependent status. I also certify that I am currently serving the University on 100% appointment and that my date of
appointment is before the final day of course registration for the term in which this discount is requested. I certify that the above student has not
registered for 132 hours at the discounted rate. I certify that I have read and agree to the specifications listed in Board Policy 440.1. I understand
that if I fail to complete this form and pay the remaining balance due on the student's account by the tuition and fee due date that I will be
subjected to late fees.
Employee Signature Date
I certify that the employee listed above is full-time (100% appointed) and is eligible for this tuition discount.
Employment Verification (by home campus) UALR Provost’s Office Final Approval Date
PVC Current as of 7/10
Total tuition discount not to exceed 132 total hours.
State of Arkansas Student Consent Form
Provost Office • 2801 S. University Ave • Little Rock, AR 72204 • (501) 569-3204 • (501) 683-7082 (FAX)
Student Name Student ID T
RELEASE OF STUDENT INFORMATION AUTHORIZATION FORM
(Act 605 of 2009)
A student who receives any form of state-supported student financial assistance, as defined by Act 605 of 2009,
must sign this form indicating whether he/she authorizes the Department of Higher Education and/or the
University of Arkansas at Little Rock to release his/her individual personal information listed below to the
Bureau of Legislative Research. (If a student is under the age of eighteen years old and is not legally
emancipated, a parent or legal guardian shall complete and sign the authorization form.)
For each student who authorizes the release of his/her individual personal information, the Bureau of
Legislative Research will receive the following information:
1. A unique student identifier 6. Gender, race, ethnicity, and age
2. Status for Federal Pell Grant 7. High school graduated from or GED test score
3. Postsecondary grade point average 8. High school grade point average
4. Number of semester hours attempted 9. ACT score or ACT equivalent score
5. Number of semester hours completed 10. Academic progress information
The Bureau of Legislative Research will collect this information for statistical analyses that will assist the
Arkansas General Assembly in evaluating whether scholarships should be increased in number or amount, the
need to change eligibility requirements, and the need for other changes to state-supported student financial
The Bureau of Legislative Research will not receive or release a student's name, social security number, or a
student's or parent's income information.
A decision to authorize or not to authorize the release of this information to the Bureau of Legislative Research
WILL NOT impact a student’s eligibility for state-supported student financial assistance, including the lottery-
funded scholarship known as the Academic Challenge Scholarship.
Please check one of the following indicating your authorization, or your decision not to authorize, the release of
the individual personal information described above to the Bureau of Legislative Research.
I do not authorize
the Arkansas Department of Higher Education and/or the University of Arkansas at Little Rock to release my
individual or my child’s personal information to the Bureau of Legislative Research.
Signature of Student Date Signed
Signature of Student’s Parent (if under the age of 18) Date Signed