oakland university tuition reduction – application & affidavit of taxability

OAKLAND UNIVERSITY
TUITION REDUCTION – APPLICATION & AFFIDAVIT OF TAXABILITY
Be sure to give all information requested.
Forms will only be accepted as early as one semester before and no later than the drop/add
for the semester. No forms will be accepted after the drop/add date for the semester.
Please keep a copy of this form for your records.
*A new Application must be completed for each semester requested.
FOR HR USE ONLY
Amt Paid_________________
Amt Rsvd________________
BANNER ENTRY ___________
Contract No.______________
Check all that apply:
Part l – DEPENDENT ELIGIBILITY
____ My child will be between nineteen (19) and twenty-three (23) during the calendar year that the tuition benefit is received and
is a full-time student. I will claim my child as a dependent in the calendar year the tuition benefit is received.
____ My child will be nineteen (19) or older anytime in the calendar year that the tuition benefit is received, is a part-time student
and his/her gross income is less than the “Standard Personal Tax Exemption”. I will claim my child as a dependent in the
calendar year the tuition benefit is received.
____ My child will be twenty-four (24) or older anytime in the calendar year that the tuition benefit is received, is a full-time
student and his/her gross income is less than the “Standard Personal Tax Exemption”. I will claim my child as a dependent in
the calendar year the tuition benefit is received.
____ I am divorced or separated, and either myself or my ex-spouse will claim my child as a dependent in the calendar year the
tuition benefit is received.
____ The dependent of an Other Qualifying Adult (OQA) will be claimed as a dependent on the OQA’s tax return in the calendar
year the tuition benefit is received.
____ My child is married or will marry during the calendar year and will not file a joint return for this year. If, however, a return is
filed, it is only as a claim for refund and not a tax liability that would exist for either spouse if they filed separate returns.
____ I am a special lecturer whose tuition benefits for myself and family combined are less than or equal to eight (8) credit hours in
this appointment year.
____ I am a retired faculty member and my dependent child was enrolled at Oakland University in the academic year or semester
immediately preceding my retirement date.
____ I am the spouse or dependent child of a deceased or disabled, full-time, non-visiting faculty member who died or was disabled
while a full-time faculty member at Oakland University.
If any of the above lines are checked, spouse or child is eligible for a tuition benefit.
PART II – EMPLOYEE INFORMATION
Employee Name_________________________________Employee Group__________Grizzly ID_________________
Position Title____________________________________Department______________________________________
Telephone____________________ Supervisor__________________________ Date of Hire ____________________
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OAKLAND UNIVERSITY
TUITION REDUCTION – APPLICATION & AFFIDAVIT OF TAXABILITY
PART III – STUDENT INFORMATION (IF EMPLOYEE IS NOT THE STUDENT)
Relationship to Employee ________________________________________________________________________
Name__________________________________Date of Birth___________________Grizzly ID_________________
PART IV – COURSE DATA
Degree__________________________________Area of Specialization____________________________________
Certificate Granting Program _________________________________ Start Date ___________________________
Completion Date ____________________________________________ Amount ____________________________
Student will attend (please check one): Year ___________ Level (please check one):
O Fall
O Undergraduate FR/SO
O Winter
O Undergraduate JR/SR
O Summer 1
O Graduate
O Summer 2
O Other
Course Title & Name Course# Credits Class Meeting Day/Time
I authorize the Human Resources Office to verify evidence of my grades for classes taken at Oakland University for the semester(s)
for which the tuition benefit was paid.
Student Signature_______________________________________________________Date_________________
STAFF ONLY. The course(s) listed above are held during my regular work schedule: O YES O NO
If yes, please specify the hours in class ___________________________________________________________
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OAKLAND UNIVERSITY
TUITION REDUCTION – APPLICATION & AFFIDAVIT OF TAXABILITY
PART V – AFFIDAVIT OF TAXABILITY
This affidavit must be completed by all employees requesting TUITION REDUCTION (TR) to determine whether Oakland University
must treat the requested TR as taxable income to the employee under Federal Internal Revenue regulations. In most cases, TR is not
taxable for undergraduate courses taken by an employee or by a spouse or child who qualifies as the employee’s dependent under
federal tax law. In addition, specific IRS rules govern the taxability of TR for graduate education, OQA and their children, and
children of divorced and separated parents. This affidavit is necessary to comply with federal tax law and to protect you and
Oakland University from potential tax liabilities and penalties. To complete the affidavit, read the following statements and INITIAL
any statement that applies to you.
1. UNDERGRADUATE TUITION REDUCTION FOR SELF, A SPOUSE, OR OQA
If you are seeking TR for your own education or that of a spouse, or OQA, initial ALL applicable statements:
____ I certify that I am applying for my own education in courses BELOW the graduate level and I understand that undergraduate
tuition benefits are not taxable to university employees.
____ I certify that the person for whom I am requesting TR: (a) is my spouse and that we have entered into a marriage recognized
under federal tax law, and we are not estranged, and that he/she does not maintain a separate domicile.
____ I am seeking TR for an OQA and I understand that 100% of the value of the TR is taxable income to me.
2. UNDERGRADUATE TUITION REDUCTION FOR AN EMPLOYEE’S CHILD OR A DEPENDENT OF AN OQA
A. If you are seeking undergraduate TR for a child whom you WILL CLAIM as a dependent on your income tax return for the year
20___, initial the following:
____ I certify that the person for whom I am requesting TR is a child that I intend to claim as my dependent on my federal income
tax return for the 20___ calendar year. If I do not claim my child as a dependent on my income tax return for the 20___ calendar
year as indicated above, I WILL NOTIFY the HR Office as soon as possible and no later than November 15 th . I understand that the
value of the TR will be rescinded and I agree to be liable for all charges.
B. If you are seeking undergraduate TR for a child, as a divorced or separated parent, whom you WILL NOT CLAIM as a dependent
on your income tax return for the year 20___, initial the following:
____ I do not intend to declare my biological child, stepchild or legally adopted child as a dependent on my federal income tax
return for the 20___ calendar year and:
(a) I am currently divorced or separated from the child’s parent;
(b) My child’s other parent will claim the child as a dependent on his/her federal income tax return for the 20___ calendar
year; and
(c) My marriage to the other parent was one that is recognized under federal law, (i.e., not an other qualified adult).
If the child’s other parent does not claim my child as a dependent for this tax year, I WILL NOTIFY the HR Office as soon as
possible and no later than November 15 th . I understand that the value of the TR will be rescinded and I agree to be liable for all
charges.
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OAKLAND UNIVERSITY
TUITION REDUCTION – APPLICATION & AFFIDAVIT OF TAXABILITY
C. If you are seeking undergraduate TR for a child, as a dependent of an Other Qualifying Adult (OQA), for the year 20___, initial
the following:
____ I am seeking TR for the dependent of an OQA and I understand that 100% of the value of the TR taxable income to me.
If the OQA does not claim the child as a dependent for this tax year, I WILL NOTIFY the HR Office as soon as possible and no
later than November 15 th . I understand that the value of the TR will be rescinded and I agree to be liable for all charges.
3. TUITION REDUCTION FOR GRADUATE EDUCATION
If you are seeking TR for graduate education for yourself or a family member, initial ONE applicable statement:
____ I am applying for TR for my own education in courses at the graduate level and I understand that I will be taxed for the value of
the TR that may exceed $5,250.
____ I am applying for TR for the education of my spouse, child, OQA, or dependent of an OQA in courses at the graduate level, and I
understand that I will be taxed for the full value of the TR.
4. GENERAL ACKNOWLEDGEMENTS - All applicants must INITIAL EACH of the following:
I understand that the following requirements are applicable to my application for and receipt of Tuition Reduction:
____ I understand the obligations set forth by Oakland University and my collective bargaining agreement or policy manual apply to
me. I certify that the listed student is eligible per guidelines set forth by my current collective bargaining agreement and/or policy
manual. This application and those documents provide the information necessary to ascertain eligibility and taxability of the benefit.
____ To the extent that any TR is taxable income under IRS regulations, the value of the TR will be added to my salary for taxation
over designated pay periods during the semester when TR is used.
5. I HEREBY AFFIRM THAT:
The information given above is true and accurate; and for compliance and audit purposes, I agree to provide to the University a copy
of any documentation (including relevant tax returns) that the HR Office deems necessary to ascertain my eligibility or the tax status
of my spouse, child, OQA, or dependent of an OQA. I understand that failure to timely provide all requested information may result
in Oakland University rescinding the benefit.
I understand that I must notify the HR Office as soon as possible and no later than November 15 th of any change in the information
that I have provided in this Affidavit. I understand that the value of the TR may be taxable income to me and applied retroactively
to the appropriate taxable year. I further understand that in the event any of the statements set forth herein are not true, or if I fail
to notify the University of any changes, the tuition for which this affidavit is being submitted will be rescinded and I will be liable for
all expenses incurred under this program.
Signature of Employee:__________________________________________________________ Date: _______________________
Signature of Supervisor (staff forms only)___________________________________________ Date: _______________________
Human Resources:______________________________________________________________ Date: _______________________
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