University System of Maryland
Senior Citizen Request for Tuition Remission
Name: ___________________________ Social Security Number:___________
Last, MI, First
Street Address: ____________________________ City: __________________
State: __________ Zip Code: ______________ Phone: _________________
Semester Applying: Check one
_____Fall
_____Spring
_____Winter
_____Summer I or _____Summer II
Academic Year: ________
Dept.
Course Section
Course Title
Credit
Hours
Meeting Times
Senior Citizens are eligible for up to 3 classes per semester.
I certify that I am at least 60 years of age and retired, that my chief source of
income is derived from retirement benefits, that I am not engaged in full-time
employment, and that I am a Maryland resident.
___________________________
Senior Citizen Signature
_______________________
Date
___________________________
Authorized HR Signature
_______________________
Date