APPLICATION FOR TUITION WAIVER BY A DEPENDENT OR SPOUSE OF A DECEASED EMPLOYEE OF

SOUTHERNN ILLINOIS UNIVERSITY EDWARDSVILLE

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 completing this form, we must receive proof of your relationship to the employee.

Spouses can provide: Marriage Certificate, Civil Union Partnership Certificate or Tax Return showing the spouse as a dependent

Dependents can provide: a birth certificate, dependents that are a step child must have a copy of the marriage license and birth certificate. We will consider other legal documentation proving a student is the dependent of an employee.

THIS FORM IS TO BE COMPLETED BY THE STUDENT

Banner ID Number:
(Last):	(First):	(Middle Initial) :
Address:	City:	State:	Zip:
Home phone number: / -	Date of Birth: / /
1. Are you currently employed by a State of Illinois University? Yes No
If yes, in what capacity? Student/GA Faculty Admin/Prof Staff Civil Service
2. Name of University you are employed by:
3. Are you an out-of-state resident?	Yes No
4. Number of credit hours you are registering for:
5. Would you attend a State of Illinois University without this waiver?	Yes No
6. What academic term are you registering for?	Fall Spring Summer - yr

Please provide the following information for the Parent/Spouse who was employed at SIUE
Name of employee (parent/spouse):
Banner ID Number:	Date of Employee’s Death:	/ /
Parent’s/Spouse’s Employee Class:	Faculty Admin/Prof Staff Civil Service
Parent’s/Spouse’s Employee Status Prior to being Deceased:	Employed	Retired On Layoff
Relationship of applicant to employee:	Spouse	Natural Child	Adopted Child or Legal Guardianship	Step Child

Statement of Draft Compliance

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 DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING COMPLIANCE STATEMENT IS TRUE AND CORRECT. I further declare that the application of this waiver serves as both official notification (unless denied) and my acceptance of this waiver. As a recipient of a tuition waiver award from Southern Illinois University Edwardsville. 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.

Applicant Signature: __________________________________________________________ Date: _______________________

FOR HUMAN RESOURCES OFFICE USE ONLY

Approved_______ Denied________ Authorized University Signature:_____________________________Date: _______________	06/24/2014 – previous versions 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.

Student Name:	Birth Date:	/ /
Student Banner ID Number
Address:	City:	State:	Zip:
Phone:	/ -
Major:	Expected Date of Graduation:
Name of Institution where previously/currently enrolled:	Southern Illinois University Edwardsville

Academic terms during which the tuition waiver benefit was utilized (specify total credit hours for which the tuition waiver was applicable – including attempted hours):

N/A – First Semester Utilizing Waiver

Semester

Year

Hours

Semester

Year

Hours

I hereby declare that all previous or concurrent academic terms, during which the 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 waiver benefit granted to me may not exceed the 4-year limitation established in 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 – previous versions obsolete

Application for 50% waiver of Undergraduate Tuition

lscrogg

2014-07-23

Joyree Chura

Southern Illinois University