Tuition Assistance Form (For Dependents)

Overview
The University of New Haven (the “University”) is committed to life-long academic achievement and learning. As such, the University offers generous tuition assistance benefits to encourage employees and eligible family members to take courses at the University in order to grow personally and professionally.

INSTRUCTIONS

This form should be submitted immediately after your dependent has registered for class but at least two weeks prior to the start of the classes. Report to Human Resources any changes made to approved classes.
EMPLOYEE INFORMATION
Name Name First Last
Department
Email
Phone Phone - ### - ### ####
Today's Date Today's Date / MM / DD YYYY
Hire Date Hire Date / MM / DD YYYY
Position/Title
Employee Group & Status:
Check all that apply

Employee Group & Status:
Check all that apply Administrative Supervisor Adjunct Clerical CLR Tutor Coach Dental Hygiene Lab Facilities Faculty PIR Police Department Full Time Part-Time (Less than 20 hours per week) Part-Time (More than 20 hours per week) Retiree Other Other
DEGREE OR PROGRAM PLAN INFORMATION
Dependent's Degree or Program:
(Note: Graduate Assistance is deemed taxable income by the IRS)

(Note: Graduate Assistance is deemed taxable income by the IRS) Graduate Undergraduate
ASSISTANCE REQUEST
Application for tuition assistance is being made for*:

Application for tuition assistance is being made for*: Spouse Dependent Child
Spouse/ Child's Full Name:
If Spouse, date of Marriage: If Spouse, date of Marriage: / MM / DD YYYY
If Child, date of Birth: If Child, date of Birth: / MM / DD YYYY
*For purposes of this policy only, an eligible dependent is defined as:
- employee’s biological child age 25 or younger; OR
- step child of the employee’s current spouse age 25 or younger; OR
- current spouse; OR
- an adopted child who was adopted prior to attaining age 18 and is 25 or younger.
Does the Student’s employer provide tuition assistance benefits?

Does the Student’s employer provide tuition assistance benefits? Yes No
If yes, please provide the name of the Student’s employer:
STUDENT STATUS & ACADEMIC TERMS
Status:

Status: Full Time Student Part-Time Student New Student Current Student
Academic Terms:

Academic Terms: Fall Semester Spring Semester Intersession Summer Session 1 Summer Session 2
Type of Program
On-Ground On-Line

(Please carefully review the provisions and exclusions related to on-line courses in the Policy)
Course #1 Information

Please enter "N/A" for all applicable fields of the course detail section.
Name of Course
Course Number(ex. MGMT 6633)
Section Number
Scheduled Time
Scheduled Days
Number of Credits
Course # 2 Information
Name of Course
Course Number(ex. MGMT 6633)
Section Number
Scheduled Time
Scheduled Days
Number of Credits
Course #3 Information
Name of Course
Course Number(ex. MGMT 6633)
Section Number
Scheduled Time
Scheduled Days
Number of Credits
Course #4 Information
Name of Course
Course Number(ex. MGMT 6633)
Section Number
Scheduled Time
Scheduled Days
Number of Credits
Course #5 Information

This is the description of your section break.
Name of Course
Course Number(ex. MGMT 6633)
Section Number
Scheduled Time
Scheduled Days
Number of Credits
ADDITIONAL INFORMATION

Please use this section for any additional information you need to provide
(ex:initial courses cancelled - replacement courses selected)
COMMENTS
6. Acknowledgement

I hereby certify that I have read and understand the provisions of the Tuition Assistance Benefit Policy & Procedure and that the information I have provided in this request is true and accurate. I further recognize and acknowledge the exclusions stipulated in the Policy and the definition of “dependent” for this policy.

I understand that the University does not cover the cost of mandatory fees and that I as the University employee am responsible for such fees. I authorize the University to deduct from my pay all fees and charges related to this application which are not paid within sixty (60) days of the beginning of this academic term. I further recognize that by signing this form, I have authorized the Payroll Department to deduct the cost of any unpaid fees and/or charges which have not been paid within 60 days of the beginning of the academic term. Additionally, I understand that upon the date of my retirement, resignation or termination, all tuition benefit assistance applicable to me shall cease. I may continue my education by remitting the appropriate tuition to the Bursar.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Tuition Assistance Form (For Dependents)

Tuition Assistance Form (For Dependents)

INSTRUCTIONS

EMPLOYEE INFORMATION

DEGREE OR PROGRAM PLAN INFORMATION

ASSISTANCE REQUEST

*For purposes of this policy only, an eligible dependent is defined as: - employee’s biological child age 25 or younger; OR - step child of the employee’s current spouse age 25 or younger; OR - current spouse; OR - an adopted child who was adopted prior to attaining age 18 and is 25 or younger.

STUDENT STATUS & ACADEMIC TERMS

Type of Program

Course #1 Information

Course # 2 Information

Course #3 Information

Course #4 Information

Course #5 Information

ADDITIONAL INFORMATION

6. Acknowledgement

*For purposes of this policy only, an eligible dependent is defined as:
- employee’s biological child age 25 or younger; OR
- step child of the employee’s current spouse age 25 or younger; OR
- current spouse; OR
- an adopted child who was adopted prior to attaining age 18 and is 25 or younger.