TUITION REMISSION AUTHORIZATION FORM

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					                                                         ADELPHI UNIVERSITY
                                               TUITION REMISSION AUTHORIZATION FORM
SEMESTER/YEAR _____

           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
STATUS:                                         STATUS:
____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:
    SAME-SEX DOMESTIC
    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.
____Graduate

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.

Fees
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