Indiana University
Revised: April 2014 University Human Resources

IU TUITION BENEFIT

Indiana University High school Tuition waiver enrollment form

Before registering for classes, check with IUHS to confirm that this form has been processed. This form must be completed and processed in order to have the tuition waiver benefit applied during course registration.

Download printable PDF of this form.

Employee Information

Name (Last, First, Middle):

Employee ID#: (printed on paycheck stub)

Home address
Number, Street, & Apt.:

City: State: Zip:

Home phone: Campus phone: Email:

Recipient (check one):
Employee     Spouse (Marriage date: )     Registered Domestic Partner
Dependent Child     Dependent Child of a domestic partner

Documentation to verify the relationship of a spouse, domestic partner, or dependent child (marriage certificate, birth certificate, domestic partner affidavit) is required with this enrollment form unless such documentation has been previously submitted. Please indicate whether you: are submitting documentation with this enrollment OR have previously submitted such documentation to Human Resources

Student Information

Dragon User ID#:
(assigned to student if previously registered for IUHS courses, otherwise leave blank)

Name: (Last, First, Middle)

Email:

Birth Date:    

Gender: Male Female

Citizenship:

 

Home address: Same as above

Number, Street, & Apt.:

City: State: Zip:

 

Complete the following for the Dependent Child Tuition Waiver:

Is the child unmarried? Yes   No
Does the child meet the IRS Support Test requirements ¬†as a Qualifying Child?    Yes   No
Is the child age 23 or under?* Yes   No
Is the child totally disabled? Yes   No

* Dependents are eligible through age 23, as long as the child meets the IRS Support Test requirements as a Qualifying Child of the employee, spouse or registered same-sex domestic partner.  Eligibility for the IUHS Tuition Waiver benefit ceases at the end of the semester in which the child reached age 24, unless the child is totally disabled.

Employee Affirmation

I affirm that all information submitted as a part of, and in support of, this application is complete and correct, including the student information section of the application, and understand that any intentionally false declaration may result in disciplinary action up to and including termination of employment at Indiana University.

Employee's signature: