Application to Receive In State Tuition by a Dependent or Spouse of a SIUE Employee

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 2013, Spring 2014, and Summer 2014 waivers would be August 31, 2013). 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	year
Please provide the following information for the Parent/Spouse who is employed at SIUE
Name of employee parent/spouse):
Banner ID Number:

Parent’s/Spouse’s Employee Class:	Faculty Admin/Prof Staff Civil Service
Parent’s/Spouses Employee Status:	Currently Employed	Retired On Layoff
Deceased
Campus Phone #:	/ -
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 DELARE 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

Employee Hire Date:____________ Eligibility: __Verified ____Denied	By__________________________________________

Date Received:__________ Date Entered: ____________ 03/06/2013 – previous versions obsolete

Application for 50% waiver of Undergraduate Tuition

LaToya Scroggins

2013-03-12

Joyree Chura

Southern Illinois University