APPLICATION FOR TUITION FEE WAIVER
Dependent/Spouse of Covered Employees
Attending Kutztown University
SECTION I – To be completed by employee. Questions should be directed to Human Resources. (PLEASE PRINT)
STUDENT NAME:
DATE OF BIRTH:
STUDENT ID:
SEMESTER (PLEASE CHECK ONE)
Fall 20____
Spring 20____
Summer I 20____
Summer II 20____
Other______________________
RELATIONSHIP TO THE KU EMPLOYEE (PLEASE CHECK ONE)
DEPENDENT
CHILD 
DOMESTIC PARTNER
CHILD 
SPOUSE
Marriage Date: ___________________ DOMESTIC PARTNER

Children of same-sex domestic partner with D.P. Certification on file
Tuition waiver for domestic partners or child(ren) of domestic partner is required to be reported as "taxable income".
EMPLOYEE NAME:
EMPLOYEE ID:
EMPLOYEE STATUS (PLEASE CHECK ONE)
ACTIVE RETIREE OTHER_________________________________________________________ JOB TITLE:
YEARS OF SERVICE WITH UNIV:
EMPLOYING UNIVERSITY:
KUTZTOWN UNIVERSITY
UNIT (PLEASE CHECK ONE)
APSCUF (Faculty)
COACHES
MANAGEMENT (Independent study/individualized instruction courses are not covered by tuition waiver)
Note: This application should be submitted no later than eight weeks prior to the deadline for payment each
semester. The tuition waiver is applicable until the student obtains his/her first undergraduate degree.
 Does student have an undergraduate degree from any college/university?
 Is DEPENDENT CHILD 25 years of age on the first day of semester?
YES (not eligible)
NO
YES (not eligible)
NO
I certify that the above i nformation is a ccurate to th e best of my knowledge and belief. I fu rther certify that the stud ent
named above meets all th e normal academic requirements for admission to Kutztown Univ ersity, and is pursuing his/her
first undergraduate degree. I understand that willful f alsification of any of this information could subject me to the full cost
of the tuition being waived, and such other penalties as applicable laws and regulations may permit.
Employee Signature
Date
SECTION II – (To be completed by Human Resources)
A C C O U N T I N G
PS TUITION:
C O D E S
PS TECH FEE:
Verified by: Initials___________ Date___________ Entered___________
The employee’s eligibility for the tuition waiver has been reviewed, and I hereby certify that the information submitted is
true and accurate to the best of my knowledge.
`
Executive Director of Human Resources
Bursar’s Office Human Resources
Date