Student Tuition Credit Form
Employee Information
Employee Name:
Employee ID:
Employee Email:
Position Title:
Collective Bargaining Unit:
Campus:
Department:
Daytime Telephone Number:
Student and Program Information
Student's Name:
Student ID:
Student is the:
Employee
Employee's Spouse
Employee's Dependent (under age 26)
Dependent's Date of Birth:
Dependent Status Certification:
I agree that this dependent meets the IRS standards of dependency and that I claimed him/her as a federal tax dependent last calendar year (or could have but was prohibited due to a Domestic Relations Order.)
Community college, state college or UMass campus where classes will be taken:
Semester:
Fall
Winter
Spring
Summer
Year
Level of Coursework:
Undergraduate
Graduate
Continuing Education
List the graduate courses being taken:
Please include course number and title of each graduate course.
Department Information
As the employee is the student, approval must be sought by the head of the employee's department.
Department Head/Supervisor Name:
Department Head/Supervisor Email:
After submission, your request will be routed to your supervisor/department head and then to Human Resources.
Contact Information