<p> TUITION ASSISTANCE APPLICATION ADJUNCT FACULTY & ELIGIBLE DEPENDENTS</p><p>*COMPLETE ENTIRE APPLICATION & RETURN TO HUMAN RESOURCES*</p><p></p><p>1. Adjunct’s Name ______2. Department ______3. Application for Tuition Assistance is being made on behalf of:</p><p> a.  Myself  Spouse  Dependent Child b. Spouse/Child’s Full Name: ______c. Name of Spouse/Child’s Employer: ______d. Does student’s employer provide Tuition Assistance benefits?  yes  no</p><p>If “yes” then student must use employer’s program as primary. UNH will coordinate Tuition Assistance with student’s employer but will not provide duplicate coverage.</p><p> g. If “spouse” – date of marriage ______h. If “child” – date of birth ______& age ______</p><p>This is to certify that the child listed above is my dependent, meets the dependent definition as established by the IRS, was so claimed on my last year’s 1040 Tax Return, and such proof can and will be provided if requested by the University.</p><p>Signature ______Date ______</p><p>4. Application for Tuition Assistance is being made for the Academic Year of ______as follows:</p><p> a.  Graduate (graduate assistance may be taxable)  Undergraduate</p><p> b.  Fall  Spring  Summer I  Summer II  UG Intercession</p><p>5. Student Status: a.  Full Time # of Credits ______(list courses below) b.  Part Time # of Credits ______(list courses below</p><p> c.  New Student  Current Student</p><p>Name of Course Course # Section # Scheduled Scheduled # of Credits Day(s) Time 1 2 3 4 5 6</p><p>I hereby certify that my answers to the above questions are true and correct. Furthermore, I authorize the University to deduct from my pay all fees and charges related to this application which are not paid within sixty (60) days of the beginning of this academic term.</p><p>Employee’s Signature ______Date ______</p><p>Please Note: Commencing on the date of an employee’s resignation and/or termination, all tuition assistance benefits applicable to you, your spouse, and/or dependent child shall cease. Employees may, at their own option, continue your education or that of their spouse and/or dependent child by remitting to the Bursar the appropriate tuition.</p><p>Tuition Assistance is applied to the cost of the class(s) only. It is the employee’s responsibility to pay for mandatory fees.</p><p></p><p>Credits Accumulated Prior Academic Year: ______Credits Used Current Academic Year: ______Balance Available Current Academic Year ______Credits This Request ______Balance for this Academic Year ______Credits Approved at Half-Tuition ______</p><p>Signature: ______Date: ______(Human Resources Representative)</p>