EMPLOYEE

							                                DEPENDENT TUITION BENEFIT APPLICATION FOR SU EMPLOYEES

                                                                                              Human Resources, Skytop Office Bldg., 443-4042
                                                                                                        1
Dependents must be eligible as defined in the Dependent Tuition Benefit Policy . The dependent tuition benefit is for
tuition charges only.

NOTE: Deadlines are different depending on whether your dependent is receiving SU tuition, a cash grant, or tuition
exchange. See appropriate section below. Please complete, print, sign and send to Human Resources by the appropriate
deadline. It is your responsibility to call HR with the name of the school your child will be attending and the single tuition
benefit option they are selecting. Failure to contact HR may result in a loss of benefit.
TUITION BENEFIT
REQUESTED                         SU/University College                      Tuition Exchange                Cash Grant

                                  Utica College – Renewal Only (must have matriculated by January 2009)

                                  First Application                Renewal Application

SU EMPLOYEE
INFORMATION                  Name:                                                   SUID#:
                             SSN:                                                    Campus Phone:
                             Campus Department:
                             Home Address:                                           Home Phone:

STUDENT
INFORMATION                  Name:                                                   SSN:                                        Date of Birth:
                             Date of Matriculation:                      Fall Semester          Spring Semester
                             Student status for period being requested:

                                  First year        Second year            Third year         Fourth year           Fifth year

                                  First time student           Returning student            Transfer student

SEMESTERS
REQUESTED                    Summer courses*              FT        PT                Fall semester          FT        PT

                             Winter semester            FT        PT                  Spring semester            FT       PT

                             Expected graduation date:

                             *Dependent tuition for summer courses is only available for students matriculated at SU or Utica
                             College.
DEADLINES FOR                First Application: November 15 for early decision applicants;
SU TUITION                                      February 1 for regular admission applicants.
                             Renewal: March 1




1
  As is the case with all benefits offered by SU, (1) the Plan Administrator has the discretionary authority to interpret the terms of the policy and such
interpretation will be binding on all interested parties to the fullest extent permitted by law, and (2) the University reserves the right to modify or terminate
the policy at any time.



HR124                                                                                                                 Revised May-06; Oct-08; April 09
                        DEPENDENT TUITION BENEFIT APPLICATION FOR SU EMPLOYEES

                                                                           Human Resources, Skytop Office Bldg., 443-4042
CASH GRANT             The cash grant is paid directly to any institution in which the student is enrolled in a degree
                       program. Checks are mailed July 1 and December 1. If applying for a cash grant to attend an
Up to $1,250 per       accredited college or university located in a country other than the United States, contact Human
semester               Resources by December 1 to discuss any additional requirements. Provide name, address and
                       phone number of institution:
                       Institution:                                                                 Phone:
Limited to eight (8)
semesters of full-
time study             Address:

                       Deadlines: First Application OR Renewal – May 1
TUITION                First or renewal application: complete this form AND the Tuition Exchange Request form.
EXCHANGE               Name of Institution
Limited to eight
(8) semesters of       Deadlines: First Application – November 15
full-time study                   Renewal Deadline – February 1
EMPLOYEE               I certify that :
CERTIFICATION          1. This student is my dependent and will be claimed as a dependent by me on my IRS tax return
OF DEPENDENT               for the tax year in which the benefit is received or I have provided alternative documentation as
STATUS                     required in the Dependent Tuition Benefits Policy; and
                       2. This student is my (select one):
Submit copy of               biological child;
Federal Tax                  child of my spouse or eligible same-sex domestic partner;
Return with                  child for whom I am the legal guardian or have legal custody; adopted child; or
application                  child who has been placed with me for adoption; and
                       3. This student will apply for the NYS Tuition Assistance Program (TAP) for this period; and
                       4. The information I have provided on this form is true to the best of my knowledge and I
                          understand that misrepresentation of any statement on this form is cause for cancellation of the
                          tuition benefit.
                       Employee Signature ______________________________________ Date ___________________

                       Please submit the first two pages of your most recent signed Federal Tax Return along with
                       this application. This documentation is required for proof of dependency. If this is not available,
                       please contact the Human Resources Service Center at 443-4042.
ELIGIBILITY            I certify that the eligibility criteria for both employee and student have been verified.
CERTIFICATION
                                  Dependent Tuition Benefit is APPROVED
Human
                                  Dependent Tuition Benefit is DENIED
Resources
Section
                        ____________________________________________                            ______________________
                        SU Office of Human Resources                                            Date


                        If denied, reason(s) for denial:__________________________________________________

                        _____________________________________________________________________________

                        _____________________________________________________________________________




HR124                                                                                          Revised May-06; Oct-08; April 09
                              DEPENDENT TUITION BENEFIT APPLICATION FOR SU EMPLOYEES

                                                                                         Human Resources, Skytop Office Bldg., 443-4042

                                CERTIFICATION OF
     FULL-TIME STUDENT STATUS FOR CERTAIN UNIVERSITY EMPLOYEE BENEFIT PLANS
I, (name)                                          , (SSN)                                            ,
certify that with respect to the child listed below,
(name)                                             , (SSN)

that such child is my eligible dependent, and the following statements are true:
1.        The child named above is unmarried, under age 25 and is matriculated as a full-time student2 at an accredited
          institution of learning and is attending such institution (as determined by the University).
2.        I understand that, in addition to the eligibility requirements described in this Certification, additional eligibility
          requirements will need to be satisfied as specified by the University’s Office of Human Resources.
3.        I understand that any misrepresentation that I make in connection with this Certification may result in (a) my
          termination of employment with the University, (b) the termination of any benefits extended to a child based on
          such misrepresentation, and (c) significant adverse tax consequences with respect to the coverage provided as a
          result of such misrepresentation. I agree to reimburse the University for any additional payments and/or expenses
          it has as a result of such misrepresentation. I understand that any entity or person including, but not limited to, the
          University, that suffers any loss because of any false statements contained in this Certification, may bring a civil
          action against me to recover such loss, including reasonable attorney’s fees.
4.        I agree to notify the Office of Human Resources in writing within 30 days of any change in status in 1
          above. I understand that such a change in status could result in ineligibility for benefits, and that I may need to
          sign certain University documents at that time.

I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF NEW YORK THAT
THE FACTS CONTAINED IN THIS CERTIFICATION, AND THE INFORMATION THAT I PROVIDE IN
ANY RELATED DOCUMENTATION AND IN ANY SYRACUSE UNIVERSITY BENEFIT ENROLLMENT
FORM(S), ARE TRUE AND CORRECT.

__________________________________________                                       ____________________________
Employee Signature                                                               Date
                                             Sign and return this form to Human Resources




2
   An eligible dependent will be considered a “full-time” student if he or she is registered for a minimum of 12 credit hours (6 credit hours if enrolled
at University College), is matriculated at, and attending, what the University determines is an accredited institution of learning.




HR124a                                                                                                                             Initiated May-06