APPLICA
ATION FOR TUITION
N WAIV
VER BE
ENEFIT
T
Forr SCUPA
A Covered EEmployeess
NOTEE: SECTION I and II must be complete
ed and III for graduate levvel courses SECT
TION I – TO BE
B COMPLETED BY EMP
PLOYEE (Ple
ease complette all questio
ons in this se
ection)
EMPLOY
YEE NAME:
EMPLOY
YING UNIVERSITY
Y:
EMPLOYEE ID:
ATTENDING UNIVERSITY:
SEMESTER A
AND YEAR:
KUTZ
ZTOWN UN
NIVERSITY
Y
COURSE
E NUMBER AND TITLE:
T
COURSE LEVEL:
CREDITS:
COURSE
E NUMBER AND TITLE:
T
COURSE LEVEL:
CREDITS:
CITIZEN
NSHIP (PLEASE CH
HECK ONE):
U.S
S. Citizen (If you are a U..S. citizen, pllease skip th
he attached p
pages 3 – 5.)
Re
esident
No
on-resident Alien
I UNDE
ERSTAND THAT I MUST MAKE UP
U ANY MISSED TIME FROM MY
Y REGULAR WOR
RK SCHEDULE AND I AM PROV
VIDING A PLAN F
FOR MAKING UP
P
TIME T
TO ATTEND CLAS
SS(ES). I ALSO UNDERSTAND
U
THAT
T
THIS INFOR
RMATION IS REQ
QUIRED TO COM
MPLY WITH CONT
TRACTUAL REQ
QUIREMENTS.
I plan
n to make up the work tim
me for attend
ding classes by3OHDVHLQFOXGHWUDYHOWLPHWRDQGIURPFODVVHV:
INDEPENDENT STUD
DY / INDIVIDUAL
LIZED INSTRUC
CTION (IS/II) CO
OURSES ARE N
NOT COVERED BY TUITION W
WAIVER. IT IS T
THE EMPLOYEE
E
RESPO
ONSIBILITY TO IMMEDIATELY REPORT ANY IS/II
I
COURSES ADDED
A
AFTER TUITION WAIV
VER FORM HAS BEEN SUBMITT
TED TO HUMAN
N
RESOU
URCES FOR TH
HAT SEMESTER
R.
The co
ourse(s) I am req
questing for perm
mission to take at
a Kutztown Univ
versity is/are und
der the tuition wa
aiver provisions of my bargaining
g unit contract. I
understand that this re
equest is for tuittion only, and th
hat I am respons
sible for all aspe
ects of the regisstration process.. A maximum of 6 credits pe
er
semestter (Fall, Spring & Summer I or II) may be taken.
Emplo
oyee Signaturre
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. Superrvisor Signatu
ure
Dire
ector Signatu re
SECT
TION III – GR
RADUATE CO
OURSES TAX
XATION
If gradu
uate level cours
ses are being ta
aken under this educational ass
sistance program
m by employeess of the universiity, the value off the educationa
al
assistan
nce may or may not be taxable to
o the employee, depending on th
he nature of the ccourses taken. G
Graduate level courses are non-taxable if they
y
are job
b-related accord
ding to IRS defin
nition. Failure to
o complete this section
s
in full wil l result in the cla
asses being treatted as non-job re
elated and will be
e
taxable. With respect to
o the listed gradu
uate level course
es taken by employees under thi s program, the ssupervisor or dep
partment head m
must complete the
e
followin
ng questions and approve Section
n III in order to be
e acceptable as job-related coursses:
Cours
se Title 1:
Cours
se Description1:
Cours
se Title 2:
Cours
se Description 2:
PLEASE CO
ONTINUE ON NEXT PAGE 
http://ww
ww2.kutztown.edu/about-ku/a
administrative-o
offices/human--resources/ben
nefits/tuition-wa
aivers.htm
Page 1
Name:
Course 1:
Semester:
Course 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
Yes
No
trade or business?
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.
Supervisor Signature
Director Signature
 ReturntoKutztownUniversity’sHumanResourcesDepartmentattheKempBuilding
SECTION IV – TO BE COMPLETED BY HUMAN RESOURCES
Graduate level section completed:
Yes
No
Employee has permanent full-time status as of Spring 2010:
Yes
No
Under 128 undergraduate credits or any combination of “U” and “G” credits up to 60 through waiver
beginning Fall 2008:
Yes
No
Under maximum of 6 credits per semester:
Yes
No
Class(es) taken during non-working hours:
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