APPLICA
ATION FOR TUITION
N WAIV
VER BE
ENEFIT
T
For A
APSCUF Covered EEmployeess
NOTEE: SECTION I and II must be completed
d and approvved if applicaable
SECT
TION I – TO BE
B COMPLET
TED BY EMP
PLOYEE (Ple
ease complette all questio
ons in this se
ection)
EMPLO
OYEE NAME:
EMPLO
OYING UNIVERSITY
Y:
KUT
TZTOWN UNIVERSITY
Y
BARGA
AINING UNIT:
ULTY ONLY)
EMPLO
OYEE ID:
ATT
TENDING UNIVER
RSITY:
SEM
MESTER AND YEAR
COURS
SE AND TITLE:
COURSE
E LEVEL:
CREDITS:
COURS
SE AND TITLE:
COURSE
E LEVEL:
CREDITS:
CITIZEN
NSHIP (PLEASE CH
HECK ONE):
U.S
S. Citizen (If you
y are a U.S
S. citizen, ple
ease skip the
e attached p
pages 3 – 5.)
Re
esident
No
on-resident Alien
I unde
erstand it is my responsibility to mee
et the deadlines for tuitio
on and fee pa
ayments at tthe university
y attended.
oyee Signaturre
Emplo
Date
SECT
TION II – DEP
PARTMENT HEAD / SUPERVISORY APPROVAL
A
Th
he class(es) will
w not interrfere with the
e employee’s
s primary dutties and is approved. Signature – Chair / Supervisor
an / Director
Siignature – Dea
Signature – Provost / VP
SECT
TION III – GR
RADUATE CO
OURSES TAX
XATION
If grad
duate level cou
urses are being
g taken under this educational assistance program by em
mployees of th
he university, th
he value of the
e
educattional assistance may or ma
ay not be taxab
ble to the emp
ployee, depend
ding on the na
ature of the co
ourses taken. Graduate leve
el
course
es are non-taxa
able if they are job-related acc
cording to IRS definition. Fai lure to complette this section in full will resullt in the classes
s
being ttreated as non
n-job related an
nd will be taxable. With resp
pect to the liste
ed graduate le
evel courses ta
aken by employyees under this
s
progra
am, the supervisor or departm
ment head mustt complete the following questtions:
Course
e Title 1:
Course
e Description1::
Course
e Title 2:
Course
e Description 2:
2
PLEASE C
CONTINUE ON
N NEXT PAGE 
http://ww
ww2.kutztown.edu/about-ku/a
administrative-o
offices/human--resources/ben
nefits/tuition-wa
aivers.htm
Page 1
Name:
Line 1:
Semester:
Line 2:
1. Are these courses required by the university, or by law or regulation, to keep the employee’s
current salary, status or job?
Yes
No
2. Do these courses maintain or improve skills required in the employee’s present work?
Yes
No
3. Are these courses required in order to meet the minimum educational requirements to qualify the
employee in his/her work or business?
Yes
No
4. Are these courses part of a program of study that will lead to qualifying the employee in a new
trade or business?
Yes
No
Courses meet the IRS definition of job-related if the answer to either questions 1 or 2 is yes and the answers to questions 3
and 4 are both no. Below, provide any additional information about the employee’s job, and how the course relates to
his/her work. If the education provides the employee in the new profession, trade or business, it is taxable even if they do
not intend to enter that trade or business.
I certify that this form is completed accurately and the course is job-related.
Signature – Department Chair / Supervisor
Signature – Dean / Director
 ReturntoKutztownUniversity’sHumanResourcesDepartmentattheKempBuilding 
SECTION IV – TO BE COMPLETED BY HUMAN RESOURCES
Graduate level section completed:
Yes
No
Faculty is tenured/on tenure track or has a 1 year full-time contract:
Yes
No
Coach has full-time regular status:
Yes
No
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
Date
SECTION V – TO BE COMPLETED BY THE BUSINESS OFFICE AT THE UNIVERSITY ATTENDED BY THE EMPLOYEE
Number of Credits
Per Credit Charge
Total Waiver
Taxable Amount
Non-Taxable
Amount
http://www2.kutztown.edu/about-ku/administrative-offices/human-resources/benefits/tuition-waivers.htm
Award Code
Page 2
STATEMENT OF CITIZENSHIP STATUS and TAXATION
\Payroll\DM\International\Statement of Citizenship Status
State System of Higher Education,
University
For Tax Year 20
In order to comply with the applicable provisions of the U.S. Internal Revenue Code, the information requested on this
form is necessary for the University to determine my proper rate of Federal tax withholding.
DIRECTIONS:
1.
2.
3.
U.S. residents complete sections A, B, C and G (as applicable)
Permanent U.S. resident immigrant, complete sections A, B, C, D and G, and attach a photocopy of your alien
registration card (green card).
All others, complete entire form, and attach a copy of your I-94 (Arrival and Departure Record) and if an
employee or contractor, your work authorization paper work (IAP66, Notice of Action, Employment Authorization Card).
A. Personal Information
Name (last, first, middle)
Date of Birth
Street address while in U.S.
Street address in country of residence
City
State
Zip Code
B. Employment Information
Faculty/Staff Employee
Local Phone #
Candidate for
a degree?
YES
NO
City
Province
Country
Postal Code
Non-employee
Student Employee
C. Social Security Information
Have you applied for either a Social Security Number (SSN) or an Individual Tax Payer Identification Number? (ITIN)
Yes My number is
No I have not applied. (In order to be paid you are required to have a SSN and in order to receive a scholarship
you are required to either have a SSN or ITIN. Your university Payroll Office can direct you to the
university representative who can assist you with this requirement. Please notify the Payroll Office when
you receive your number.)
D. Citizenship and Visa Information
Citizen of (Country)
Resident of (Country)
What country issued you a passport?
Passport Number
Is this your first visit to the U.S.?
Most recent date entered
U.S.
Yes
Visa type on I-94
What is the primary purpose of your
Visit to the U.S.?
No If no, please list all entries into the U.S. and the previous visa types:
Expiration date of I-94
Intended length of stay in
U.S.
Anticipated departure
date (if known)
Page 3 of 5
E. Certification of Tax Exemption
Note 1: This does not apply to Commonwealth of Pennsylvania or Local Withholding Taxes.
Note 2: Certification of Federal tax exemption must be renewed each tax year.
Note 3: Annually, employees receiving payment for services must complete IRS Form 8233 and the tax treaty
statement to claim tax treaty benefits.
Note 4: Non-employees receiving payment for independent personal services must complete IRS Form 8233 to claim
tax treaty benefits.
You may be eligible for exemption from Federal Tax withholding because there is an applicable tax treaty between
your country of residence and the U.S. and your duties while in the U.S. are:
Yes, I certify I am not a citizen or resident of the U.S., that I am eligible for tax exemption because there is a
current tax treaty between my country of residence and the U.S., and my duties while in the U.S. are:
Treaty Article
Teaching
Student
Other (describe)
No, I am not exempt from Federal Tax withholding.
F. Determination of Federal Tax Withholding Status. (To be completed by alien.)
Follow directions for each test. Complete Summary of Tax Status.
Test 1: Exemption from Substantial Presence
Check any applicable statement:
I have a Type A visa or Diplomatic or Consular status.
I have a J-1 visa and I was in the U.S. as a teacher, trainee, researcher, or student on a J-1 or F-1 visa for less
than 2 calendar years of the preceding six years.
I am a student on an F-1 or J-1 visa and have been in the U.S. for five or fewer calendar years.
I am a student on an F-1 or J-1 visa and have been in the U.S. for more than five calendar years, and I have
established with the IRS that I do not plan to reside in the U.S. when my education is completed.
(Attach IRS notification letter)
If you marked any box, you are a nonresident alien for tax purposes. Please complete Summary of Tax Status.
If you did not mark a box, go to Test 2.
Test 2: Substantial Presence Test (SPT)
I have been present in the U.S. during the current and the previous two years as follows:
Enter year
Date Entered
U.S.
Date Departed
U.S.
Number of
Days in U.S.
Computation
of SPT
Current
Year
x1
=
1st
preceding
Year
x 1/3 =
2nd
preceding
Year
x 1/6 =
Total:
Days
Check One:
Total less than 183 days. You are a nonresident alien for tax purposes. Please complete Summary of Tax Status.
Total equal to more than 183 days, go to Test 3.
Page 4 of 5
Test 3: Exception to the Substantial Presence Test
Check applicable box:
Have you been in the U.S. for less than 183 days during this calendar year? AND do you pay taxes in your country of
residence? AND do you have a closer connection to that country than to the U.S.?
Yes If yes to all, you are a nonresident alien for tax purposes. Please complete Summary of Tax Status.
No If no to any, you are a resident alien for tax purposes. Please complete Summary of Tax Status.
SUMMARY OF TAX STATUS
Mark appropriate Federal Tax withholding status:
Resident alien (complete W-4)
Nonresident alien
G. Signature
I declare under the penalties of perjury that this statement, to the best of my knowledge and belief, is true and correct.
Department Contact:
Phone:
Signature
Date
PRIVACY NOTIFICATIONS
Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your Social Security Number is
mandatory. Disclosure of the Social Security Number is required pursuant to sections 6011 and 6051 of Subtitle F of
the Internal Revenue Code and with Regulation 4, Section 404.1256, Code of Federal Regulations under Section 218,
Title II of the Social Security Act, as amended. The Social Security Number is used to verify your identity. The
principal uses of the number shall be to report (1) state and federal income taxes withheld, (2) Social Security contributions, (3) state unemployment and Workers' Compensation earnings, and (4) earnings and contributions to
participating retirement systems.
University Use: Determination of Value of Scholarship/Waiver
Award Recipient:
Relationship:
Award Type:
Award Name:
Semester:
Status:
STAFF or STUDENT
UNDERGRADUATE or GRADUATE
Taxable Amount:
Benefit Code:
Authorized By:
Date:
Page 5 of 5
Payroll Dept. Only
Date input in HRS
Pay Date
Initials