Dependents of permanently Disabled, Retired or Deceased Employees

This form is only for FIRST TIME USERS of the DEPENDENT TUITION REMISSION BENEFIT: If your dependent received tuition remission in a previous semester, please DO NOT submit a request

Student / Dependent UofL ID Number

Requesting for Term

Spring 2018

Student / Dependent First Name

Student / Dependent Last Name

Student / Dependent Date of Birth

Year/Month/Day

Student / Dependent E-Mail Address

Dependent Status

A dependent child (birth, legally adopted, legal ward, or stepchild) reported by me as a dependent for tax purposes. Dependent child is taking courses toward their first undergraduate degree. Hire date AFTER 07-01-78: Dependent child has not attained the age of 26 as of the first day of classes for the semester. Effective Fall 2012, total tuition remission benefits for a dependent child shall be limited to 144 credit hours (including credit hours transferred to UofL, if any).

A dependent child (birth, legally adopted, legal ward, or stepchild) who is NOT reported by me as a dependent for tax purposes, but is nevertheless my dependent because I provide more than 50% of his/her financial support. Dependent child is taking courses toward their first undergraduate degree. Hire Date AFTER 07-01-78: Dependent child has not attained the age of 26 as of the first day of classes for the semester. Effective Fall 2012, total tuition remission benefits for a dependent child shall be limited to 144 credit hours (including credit hours transferred to UofL, if any).

An emancipated child whose parent permanent full-time employment prior to February 18, 1966 and is pursuing the first undergraduate degree.

The spouse of a faculty member who has had continuous, regular, full-time employment on, or before, July 1, 1978.

Employment Status

An employee hired prior to July 1, 2011 who is permanently disabled, retired or deceased.

Employee UofL ID Number

Employee First Name

Employee Last Name

Employee E-Mail Address

Acknowledgement

Submitting this form acknowledges the following: Claiming benefits under the tuition remission program for anyone who is subsequently determined to be ineligible shall be construed as a misappropriation of University funds and subject the sponsoring employee to discipline, including dismissal, and the forfeiture of any tuition remission benefits previously received.

Human Resources

Dependents of permanently Disabled, Retired or Deceased Employees