Application for Interinstitutional 50% Waiver of Undergraduate Tuition

by a Child of a 7 Year Illinois University Employee Attending SIUE

PLEASE NOTE: No tuition and fee waiver request form will be approved or processed after the last official day to withdraw from classes and receive a full refund. Incomplete forms will not be processed and will be returned to the student. To avoid being incorrectly billed, students should register BEFORE completing the form. Completed forms are to be submitted to the Office of Human Resources. Please note the application is good for one academic year. The application deadline for tuition waivers for each academic year is August 31. (Example: The deadline for Fall 2014, Spring 2015, and Summer 2015 waivers would be August 29, 2014). Applications summited for Spring or Summer semesters are due by the 10th day after the start of the semester. Forms received after the deadline will not be processed.

If this is the first year/semester a dependent is completing this waiver to attend Southern Illinois University Edwardsville we must receive a copy of the birth certificate. If the dependent is a step child we must have a copy of the marriage license and birth certificate.

THIS FORM IS TO BE COMPLETED BY THE STUDENT (Must complete all pages)

Application for 50% Tuition Waiver at: Southern Illinois University Edwardsville

Student ID Number at University Student is attending (required):
Student Email at University Student is attending (required):
(Last):	(First):	(Middle Initial) :
Address:	City:	State:	Zip:
Home phone number: / -	Date of Birth: / /
Student’s Campus Address:
City:	State:	Zip:
Student’s Permanent Address:
City:	State:	Zip:
What academic term are you registering for?	Fall Spring Summer - yr

Student Certification of Registration Compliance & Acknowledgement of Policies

I certify that I am registered with the Selective Service

I certify that I am not required to register with the Selective Service because:

I am female.

I am in the Armed Services on active duty. (NOTE: Does not apply to members of the

Reserves and National Guard who are not on active duty.)

I have not reached my 18th birthday.

I was born before 1960.

I am a citizen of the Federated States of Micronesia, or the Marshall Islands or a permanent

resident of the Trust Territory of the Pacific Islands (Palau).

I am an international student (applicable only to State of Illinois funded programs.)

I am an incarcerated student.

I hereby declare that the Student Certification of Registration Compliance is true and correct and that I am a child or stepchild who is eligible for the 50% tuition waiver pursuant to P.A. 90-0282 and related policies/procedures. I request and understand that this information will be verified by accessing university records, and that total partial undergraduate tuition waiver benefits granted to me may not exceed the 4-year limitation established in P.A. 90-0282. In the event this application contains any false statements, errors or omissions pertaining to my parent's service record or in the event total partial undergraduate tuition waiver benefits among eligible institutions exceed the 4-year limitation, I will be responsible for the full value of any ineligible benefits that I may have received.

I understand that a separate "Tuition Waiver Benefit Utilization Record" must be completed for each institution in which I have been enrolled while utilizing these tuition waiver benefits, that the tuition waiver benefit utilization record may be subject to verification by the tuition waiver granting institution, and that tuition waiver approval protocols shall be subject to individual university policies. (See attached policy statement for additional information.)

PLEASE NOTE: To avoid being billed incorrectly the student should register for classes before completing/submitting this form. Tuition waivers at SIUE are due in the Office of Human Resources by the 10th day after the official start of the semester. Tuition waivers received after the deadline will not be processed.

As a recipient of a tuition waiver award from Southern Illinois University, I understand that the University has the legal authority to release my name and address, the name of my former high school or college, the name of my award, and the award amount. This release is valid for the period of time the tuition waiver is in effect. The refusal to accept this agreement will result in a forfeit of the waiver.

Student Signature:

Date:

06/24/2014 – pervious version obsolete

Parent’s Disclosure/Certification of Illinois Public University Employment

Instructions: Please complete the following information as thoroughly as possible. All items must be completed. Percentage and dates of employment must be listed for each position claimed. The human resource or personnel office at listed universities may formally confirm the employment record and/or parent/child relationship through the use of University employment/benefit records at all locations for which employment credit is claimed. Confirmation procedures may require additional documentation.

Student ID Number at University Student is attending (required):
(Last):	(First):	(Middle Initial) :

University at which the employee is currently employed:
Chicago State University
Southern Illinois University-Carbondale
Eastern Illinois University
Southern Illinois University-School of Medicine
Governor State University
University of Illinois-Chicago
Illinois State University
University of Illinois-Springfield
Northeastern Illinois University
University of Illinois-Urbana/Champaign
Northern Illinois University
Western Illinois University

Qualified Employee (Parent) Name:
University ID Number at Employing University:
Work Phone:
Work Email:
Parent’s Employee Class:	Faculty Admin/Prof Staff Civil Service
Parent’s Employee Status:	Currently Employed	Retired On Layoff Deceased

To be completed by Applicant/Parent (use additional sheet if necessary_
Institution (branch or location, list current employer first)	Start Date (mm/dd/yy)	End Date (mm/dd/yy)	Percent of Employment
/ /	/ /
/ /	/ /
/ /	/ /
/ /	/ /

I hereby declare that this student is my child or stepchild. All information provided is accurate to the best of my knowledge.

Employee Signature: __________________________________________________________ Date: _______________________

FOR OFFICE USE ONLY

Applicant Information Confirmed/Corrected	Authorized University Signature	Authorized University Printed Name	Title

Date

Account #

Amount:
HR Initials
Date:

06/24/2014 – pervious version obsolete

TUITION WAIVER BENEFIT UTILIZATION RECORD

Public Act 90-0282

Instructions: The following information must be completed by the student, certified by the department responsible for monitoring academic record(s), and attached to the Tuition Waiver Application in the event that you have (are) already accessed(ing) the 50% tuition waiver benefit at Southern Illinois University Edwardsville and/or another Illinois public university.

Student Name:	Birth Date:	/ /
Student ID Number at University Student is attending (required):
Address:	City:	State:	Zip:
Phone:	/ -
Application for 50% Tuition Waiver at (name of university):
Major:	Expected Date of Graduation:
Name of Institution where previously/currently enrolled:

Application for 50% Tuition Waiver at (please select all schools you have utilized the waiver at):

Chicago State University

Southern Illinois University-Carbondale

Eastern Illinois University

Southern Illinois University-Edwardsville

Governor State University

University of Illinois-Chicago

Illinois State University

University of Illinois-Springfield

Northeastern Illinois University

University of Illinois-Urbana/Champaign

Northern Illinois University

Western Illinois University

N/A – First Semester Utilizing Waiver

Academic terms during which the 50% tuition waiver benefit was utilized at any Illinois Public University (specify total credit hours for which the 50% tuition waiver was applicable – including attempted hours):

University

Semester

Year

Hours

University

Semester

Year

Hours

I hereby declare that all previous or concurrent academic terms, during which the 50% tuition waiver benefit was utilized, are accurately accounted for above. I request and understand that this information may be verified by means of accessing university records and that the total partial undergraduate tuition waiver benefit granted to me may not exceed the 4-year limitation established in P.A. 90-0282. A separate "Tuition Waiver Benefit Utilization Record" must be completed for each institution in which the student has been enrolled while utilizing tuition waiver benefits pursuant to P.A. 90-0282.
Student Signature
Date
FOR OFFICE USE ONLY
50% tuition waiver benefit utilization record confirmation (optional as requested by the tuition waiver granting institution): In accordance with institutional standards for tuition waiver benefit utilization, the record outlined above is correct.

Name
Authorized signature of record confirmation

Employee Records
Date

06/24/2014 – pervious version obsolete

Application for 50% waiver of Undergraduate Tuition

lscrogg

2014-06-24

Southern Illinois University