TUITION REMISSION AUTHORIZATION FORM
STUDENT INFORMATION EMPLOYEE INFORMATION FINANCIAL AID INFORMATION
The student named herein has completed
________________________ ___________________________ all necessary financial aid forms for the
NAME NAME _________ semester.
SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER ______________________________
Student Financial Services Signature
____FULL-TIME STUDENT ____FACULTY ATTENTION:
____PART-TIME STUDENT ____NON-UNION
____UNDERGRADUATE ____PUBLIC SAFETY As of Fall, 2005, when an employee
____GRADUATE ____LOCAL 1102 terminates employment for any reason
____LOCAL 153 during a semester in which he/she, the
____EMPLOYEE ____APPWLU spouse, same-sex domestic partner (if
____SPOUSE ____COACH eligible), or dependent child has tuition
____SAME-SEX DOMESTIC remission, he/she will be billed for a
PARTNER (if eligible) prorated portion of the tuition charge.
____DEPENDENT CHILD ____FULL-TIME EMPLOYEE
____DEPENDENT CHILD OF ____PART-TIME EMPLOYEE DEADLINE:
PARTNER (if eligible) To be completed by Supervisor: As of Fall, 2005, tuition remission forms
MUST be fully completed and submitted
Do you have a degree? _________________________ to the Office of Human Resources on or
___ Yes ___No Department Name & Number before the DROP date for the semester
or cycle in which the tuition remission is
If yes, type of degree _________________________ being requested. No forms will be
________________ Chair/Supervisor Signature accepted or processed after the drop
date and any tuition or fees due for
Level of coursework: ___________________________ coursework completed will not be
____Undergraduate Human Resources Signature waived.
Taxability of Tuition Remission for Graduate Coursework
Employees: Tuition remission for graduate coursework that exceeds $5,250 per calendar year will be subject to taxation
unless the employee is taking courses and/or a degree which is work-related and the employee receives an approved
exemption in writing, from the Controller's Office. All requests must be submitted prior to the first day of classes.
Spouses: Employees whose spouses receive tuition remission for graduate level courses will be taxed for the full
value of the remission received and the full amount of the remission will be included on the employee's W-2.
NOTE - Employees, their spouses and dependents are not, at this time, subject to federal or state income tax for the
amount of undergraduate tuition remission received.
Same-Sex Domestic Partner/Child of Same-sex Domestic Partner (if eligible) - Employees will be taxed the full value of
undergraduate and graduate tuition remission given to same-sex domestic partners and/or children of a same-sex
domestic partners unless the partner or child can be declared a dependent of the employee for tax purposes.
All fees are paid by the student within the designated deadlines. Any applicable taxes are the responsibility of the
employee. It is University policy that approval for tuition remission is governed by the rules and regulations of
the University tuition remission policy. I have read and understand the foregoing statement.
I certify that the student named above is myself, my spouse, same-sex domestic partner (if eligible) , or dependent child.
WHITE: HUMAN RESOURCES YELLOW: STUDENT ____________________________
Revised 5/05 Employee Signature/Date