ANDERSON UNIVERSITY
APPLICATION FOR GRADUATE TUITION BENEFITS
Instructions: Before completing this application, you must apply to and be accepted by the graduate program.
Complete Section 1, obtain the required signatures in Section II, and submit this application to Human
Resources. For full consideration, your Graduation Tuition Benefits Application should be submitted by June 1
before you anticipate beginning classes.
SECTION I: STUDENT APPLICATION
NAME:
University ID#
Position and Department:
FTE:
Graduate Program for which tuition benefits are requested:
Provide a brief statement regarding how this graduate program is applicable to your University assignment,
career goals and/or improves the skills needed in your job.
TUITION BENEFITS REQUESTED (May be completed for entire program. Attach additional sheet if necessary.)
Tuition Charge to be Remitted
SCHOOL TERM Year 1
Graduate Credit Hours
(To be completed by Graduate Program.)
Semester I
-
$
Semester II
-
$
Summer Session I
-
$
Summer Session II
-
$
Summer Session III
-
$
Summer Session IV
-
$
09/01/2008
Tuition Charge to be Remitted
SCHOOL TERM Year 2
Graduate Credit Hours
(To be completed by Graduate Program.)
Semester I
-
$
Semester II
-
$
Summer Session I
-
$
Summer Session II
-
$
Summer Session III
-
$
Summer Session IV
-
$
Please Note: Graduate tuition benefits are tax-free up to $5,250; any excess is taxable to you unless the graduate course
work is a job requirement meeting the following "working-condition fringe benefit" tests:
1. The education is required by the University or by law for you to keep your present salary, status or job. The
required education must serve a bona fide business purpose of the University.
2. The education maintains or improves skills needed in your job.
EMPLOYEE CERTIFICATION
This application for Remitted Tuition benefits is true and correct to the best of my knowledge. I understand I
am responsible for any financial consequences resulting from a misrepresentation of information, including
loss of benefit and assumption of related charges. I understand I am obligated to remain employed at
Anderson University for 24 months after ending or completing this program. Should I leave the University, I
agree to reimburse a prorated amount of the tuition benefit I received.
Signed:
Date Signed:
SECTION 2: GRADUATE PROGRAM CERTIFICATION (To be completed by Graduate Program representative.)
The employee has been accepted into above program.
Yes
Date Program Begins:
Anticipated Graduation Date:
Authorized Signature:
Date Signed:
SUPERVISOR CERTIFICATION
I approved of this employee’s enrollment in the above graduate program. I understand employment
expectations and performance standards are unchanged during the educational program.
Signed:
Date Signed:
HUMAN RESOURCES CERTIFICATION
REMITTED TUITION BENEFIT ELIGIBILTY: _______%
Signed:
Date Signed:
Calendar/Tax Year
Total Benefit
$
$
$
Non-Taxable
$
$
$
Taxable
$
$
$
09/01/2008