Graduate Assistantship Tuition and Fees/Health Insurance Designation Form
Fall/Spring 2015-2016 (201610-201620)
THIS IS A:
New form
Change in account
Change in Hours
Other:
W Number
Last Name
First Name
Middle Name
College
Department
Completed By
Phone
Date
W
STIPEND SOURCE
Acad Affairs Base
(URDM)Mentoring
Dept/Other:
½ GA
Other
Full GA
SOURCE OF FUNDS FOR TUITION AND FEE REDUCTION
Account Number(s)/Grant ID(s) – Program and special course fees are
covered for all AA state funded GAs – New 2015-16
Fall (201610)
Credit
Hours
Amount(s)
Remarks
Optional Fee Package $343.19
Other
Half GA - Up to 5 Credits
Full GA - Up to 9 Credits
Full GA - Up to 12 Credits *
Spring (201620)
*If > 9, coursework is required for degree curriculum
Optional Fee Package $343.19
Other
Half GA - Up to 5 Credits
Full GA - Up to 9 Credits
Full GA - Up to 12 Credits *
SOURCE OF FUNDS FOR HEALTH INSURANCE,
DEPARTMENTAL, OR OTHER FEES
*If > 9, coursework is required for degree curriculum
List all
Account Number(s)/Grant ID(s)
Amount(s)
International
Fall $850.00
Fall (201610)
Domestic
Fall $708.00
Other $
Other $
Spring (201620)
Domestic
Spring $1048.00
Other $
Other $
Remarks
International
Spring $906.00
SIGNATURES
Department or Division Head
Date
College Dean
Academic Affairs
*Complete and return to Michele Peck, Academic Affairs, Old Main 312
*Deadline for submission of paperwork is August 21, 2015, for Fall and January 15, 2016, for Spring
Date
Date
Revised 7-13-2015