DSLCC Student Tuition Assistance Agreement for Senior Citizens
Name:____________________________________________ EMPLID:___________________
SSN:________________________________________ Date of Birth: _____________________
Address: _____________________________________________________________________
Telephone Home: _________________________ Business: ___________________________
CREDIT COURSES
_____I hereby certify that I am qualified for free tuition for credit courses by meeting the following
criteria:
 am 60 years of age or older;
 am a legal domiciled resident (12 months) of Virginia;
 had an individual taxable income not exceeding $23,850 for Virginia Income tax purposes for
the year preceding the year in which enrollment is sought;
 been admitted to the College as a student.
AUDIT COURSES/NON-CREDIT COURSES
_____I hereby certify that I am qualified for free tuition for auditing of credit courses or for taking noncredit courses (not to exceed three courses per semester) by meeting the following criteria:
 am 60 years of age or older;
 am a legal domiciled resident (12 months) of Virginia;
 have been admitted to the College as a student.
NOTE 1: Senior citizens taking any class without paying tuition will be registered on a space available
basis with priority given to tuition-paying students. Non-paying senior citizens may be withdrawn from
a class after it has begun in order to make room for a paying student who registers during the add/drop
period; in this event, the senior citizen has the option of paying for and remaining in class.
NOTE 2: For verification purposes, the college reserves the option of reviewing the Virginia tax form on
which the eligibility is based. A DSLCC employee will verify income and initial below. The tax form will
be returned to the student and will not be copied in any way.
NOTE 3: Senior citizens will be responsible for the payment of any fees associated with the course, such
as laboratory fees.
_____I certify that my individual taxable income on my most recent Virginia tax return was $23,850 or
less.
_____ Auditing or Non-Credit. No income requirement.
Student Signature _______________________________________________ Date _________________
Individual Virginia Taxable income form verified by DSLCC employee (initial): _____________________
07/01/15