PASSHE LogoKutztown University
 
  
APPLICATION FOR DEPENDENT TUITION WAIVER BENEFIT

Name of Employee/Annuitant:

Work Group * 
  Name of Employing University: Kutztown University

Name of Student:

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Relationship of Student to Employee/Annuitant: * 
 
SEMESTER (PLEASE CHECK ONE) *
 
Does this student have an undergraduate degree from any college/university? * 
Is DEPENDENT CHILD 25 years of age on the first day of semester? * 
Is this the student first semester attending a PASSHE school? * 
Please select your preference to submit the proof of age document. * 

Please contact Human Resources at 610-683-1353 for assistance.

Note: Your tuition waiver will be held until Human Resources received the proof of age document. Please bring a copy to the Kemp Building as soon as possible.

Employee/Annuitant Verification: I hereby certify that the above named student qualifies as my child in accordance with, and meets the qualifications as defined by, the APSCUF or SCUPA Collective Bargaining Agreement or the Board of Governors Policy 1984-03-A. I agree to provide to the university proof of relationship and age as may be required. I understand it is my responsibility to meet the deadlines for tuition payment at the university attended by the student.

Employee's Signature (you may sign with your mouse or sign with fingers on a touch screen device) *
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(Guardian or Beneficiary may provide verification of relationship in the Event of Employee’s/Annuitant’s Death) 

UNIVERSITY USE ONLY

HUMAN RESOURCES DEPARTMENT at employing university:  The employee’s/annuitant’s eligibility and student’s qualifications for the tuition waiver have been reviewed, and I hereby certify that the information submitted is true and accurate to the best of my knowledge.
 
 
 
  
_________________________________________________________________           _________________
Signature & Title                                                                                                     Date

Send tuition invoice to:  KUTZTOWN UNIVERSITY • ATTN: HUMAN RESOURCES / KEMP BUILDING • PO BOX 730 • KUTZTOWN PA 19530-0730


If you do not receive a confirmation email, please check spam.  Please contact Human Resources should you have any questions regarding tuition waivers.