2014-2015 Qualified Dependent
Educational Benefits Request Form
See Page 2 for Instructions - Incomplete Information Will Delay the Process
EMPLOYEE INFORMATION
Name:
Last,
First,
Employee ID#:
OHIO email
address:
Phone:
M.I.
*Address:
Street Address
City
State
*Use HOME address
**If employee is deceased use student’s address as
student will then be responsible for taxes, if
applicable.
Zip
Employee is/was: Check all that apply
Administrative Staff
Classified (Non-Bargaining)
Classified (Bargaining)
Faculty
Military Science
Full Time
Part Time
Contract Group II FTE:
Retired – Effective ____________
Approved Leave
Deceased
Severance - Effective __________
Employee Signature: _______________________________________Date:
__________________
As the employee, I understand that I will be subject to withholding taxes under regulations of the Internal Revenue Service for non-tax dependent
children receiving undergraduate benefits and any child or spouse receiving graduate benefits. Withholding taxes apply to benefits provided to
Domestic Partners enrolled in both undergraduate and graduate level courses.
ENROLLMENT INFORMATION:
Term(s) of Enrollment: Check all that apply
Fall
Spring
Program Enrolled:
Certain Programs are not eligible, please see following
page for details
Summer
STUDENT INFORMATION:
Student email:
Name:
Student PID#:
Last,
First,
M.I.
CHECK ONE (Child Both Tax Years Need To Be Checked):
Child
Child is a dependent for tax purposes in 2014
Child is a dependent for tax purposes in 2015
Spouse
Domestic Partner* (Affidavit on File with the Benefits Office)
CHECK ONE:
Graduate
Yes
Yes
No
No
NOTE:
First year students
(undergraduate or graduate)
DO NOT submit until
registration is complete.
Please see back for details.
Undergraduate
Student Signature:
Date:
I hereby apply for the Educational Benefits Program for undergraduate and/or graduate study for qualified dependents of faculty, administrative, and classified
employees at Ohio University. I understand that eligibility for this benefit is contingent upon continued employment status or retirement of the employee, whose
signature appears above.
**If the employee associated with the benefit is deceased, I understand I will be responsible for any taxes incurred based on IRS parameters. Please see the back of
this form for further information.
For office use ONLY
Benefit
Amount
Org
Number
Dependency
INSTRUCTIONS FOR COMPLETING THE EDUCATIONAL BENEFITS REQUEST FORM
FOR QUALIFIED DEPENDENTS OF OHIO UNIVERSITY EMPLOYEES
1)
Complete the request form thoroughly.
a.
If the employee is retired or deceased remember to also include their employee number.
b.
If the employee is deceased, please provide the student's home address in the employee information section.
2)
List PID number. Form cannot be processed without that information. If PID is unknown, please contact the Registrar’s
Office.
3)
Check the proper person receiving the benefit (e.g. Child, Spouse, or Domestic Partner).
a. For children make sure to check BOTH years for tax purposes
b. CHECK Graduate or Undergraduate (enrolled in both check both boxes)
4)
Indicate your program in Program Enrolled. If not in a program, put NO PROGRAM.
5)
Timely submission of this form can ensure correct billing.
a. PLEAE NOTE – Accounts will not be created until registration of classes is completed for the following (Please wait
to submit form until registration is complete):
i. First Year Students
ii. Graduate Students who have not yet been accepted or have not yet registered
Information Regarding the Educational Benefits Program

The Educational Benefits Request Form must be submitted once every academic year.
o
For tax purposes, be sure to use the appropriate academic year form.
o
New forms for the upcoming Academic Year will be available each April.

Dependents of Full-time, Benefits Eligible Employees; 100% of the instructional fees and non-residency fees (when
applicable) will be waived.

Dependents of Part-time, Benefits Eligible Classified Employees; 50% of the instructional fees and the non-residency
fees (when applicable) will be waived.

Dependents of Part-time, Benefit Eligible Faculty & Administrators working at .67 of a full-time equivalent (FTE) or
more, the benefit is 100% of the instructional fee and 100% of the non-residency fee (when applicable). A FTE of .66 or
less will receive pro-rated benefits (instructional and non-residency fees) matching their FTE.

The Educational Benefits Credit will be applied to your account automatically each semester and will adjust according to the
number of hours enrolled. Timely submission of this form can ensure correct billing

Educational programs offered through Community and Professional programs are not eligible for educational benefits.

Certain programs noted on the following site are not eligible for educational benefits. Visit
http://online.ohio.edu/partnerprograms.htm for more information.
Taxation
If the employee associated with the benefit is deceased, the student will be responsible for any taxes incurred based on Internal
Revenue Service parameters.
Benefits



will be subject to withholding taxes under regulations of the Internal Revenue Service for the following:
Children who are non-dependents for tax purposes and are enrolled in undergraduate courses
Children or spouse enrolled in graduate level courses
Domestic Partners enrolled in both undergraduate and graduate level courses
To view the tax withholding schedule, visit the Payroll website at: http://www.finance.ohiou.edu/payroll/employeeinfo.htm

Click Employee Payroll Info
Please return this form and direct questions to:
Ohio University Human Resources
Attn: Educational Benefits – Angela Mosher
Human Resources & Training Center
169 West Union Street, Athens, OH 45701
T: (740) 593-1648
F: (740) 593-0669
*Email: sinclaa1@ohio.edu
* Emailed/faxed forms do require appropriate signatures AND do not require hard copy
http://www.ohio.edu/hr/benefits/educational/index.cfm
NOTE: In accordance with Federal and State Financial Aid Law, if you receive any Federal, State, or Ohio University student financial aid as a result of incomplete or incorrect information, or
your financial aid status changes, you must repay all financial aid to which you were not entitled. Any person who knowingly makes a false statement or misrepresentation in the application for
student financial aid is in violation of the law and is subject to criminal prosecution and also subject to Ohio University disciplinary action.