"State Employee Tuition Waiver Program Participation Template Form" - Florida

State Employee Tuition Waiver Program Participation Template Form is a legal document that was released by the Florida Department of Management Services - a government authority operating within Florida.

Form Details:

  • Released on September 28, 2016;
  • The latest edition currently provided by the Florida Department of Management Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Management Services.

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STATE EMPLOYEE TUITION WAIVER PROGRAM
PARTICIPATION TEMPLATE FORM
_____________________________________________
Name of State University or Florida College System Institution
By completing this form you are requesting agency approval to participate in this program. You
will still need to complete the appropriate forms of the school you are attending.
Name
Agency
Phone #
Division
Bureau
Address
City
State
Zip Code
Email Address
I am requesting a waiver for
___ Fall ___ Spring ___ Summer Year ________
Date of first day of classes (if known) _______________
Name of Courses: List the course number, title and the number of credit hours
Course
Please list up to 4 courses, 2 preferred, 2 alternate
Credits
Costs/Value
ID
per credit hour
Preferred
Preferred
Alternate
Alternate
Total Costs/Value:
Section 127, Internal Revenue Code, permits employers to offer undergraduate and graduate education
benefits to employees on a tax-free basis, up to $5,250 per calendar year. If the annual value of the state
employee fee waivers exceeds $5,250, then the excess will be reported to State Payrolls as taxable income.
I, the undersigned, acknowledge the following:
My waiver of tuition and fees will apply to no more than six credit hours per term.
I must register for classes during the State Employee registration period prescribed by the state
university or Florida College System Institution that I plan to attend.
All other charges/fees are my responsibility.
My ability to secure the courses I request depends on space availability.
NOTE: Participating employees should be aware that the school at which you apply may require you to
provide your social security number to verify employment.
______________________________________
______________________________________
Employee Signature
Date
Agency Authorization
I authorize the above named employee to participate in the Tuition Waiver Program. I also certify that the
above-named employee holds an established authorized position with a full time equivalency (FTE).
Supervisor’s name (please print)
Supervisor’s Signature
Title
Date
Agency Head or designee (please print)
Agency Head or designee Signature
Title
Phone #
Date
09/28/2016
TEMPLATE
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STATE EMPLOYEE TUITION WAIVER PROGRAM
PARTICIPATION TEMPLATE FORM
_____________________________________________
Name of State University or Florida College System Institution
By completing this form you are requesting agency approval to participate in this program. You
will still need to complete the appropriate forms of the school you are attending.
Name
Agency
Phone #
Division
Bureau
Address
City
State
Zip Code
Email Address
I am requesting a waiver for
___ Fall ___ Spring ___ Summer Year ________
Date of first day of classes (if known) _______________
Name of Courses: List the course number, title and the number of credit hours
Course
Please list up to 4 courses, 2 preferred, 2 alternate
Credits
Costs/Value
ID
per credit hour
Preferred
Preferred
Alternate
Alternate
Total Costs/Value:
Section 127, Internal Revenue Code, permits employers to offer undergraduate and graduate education
benefits to employees on a tax-free basis, up to $5,250 per calendar year. If the annual value of the state
employee fee waivers exceeds $5,250, then the excess will be reported to State Payrolls as taxable income.
I, the undersigned, acknowledge the following:
My waiver of tuition and fees will apply to no more than six credit hours per term.
I must register for classes during the State Employee registration period prescribed by the state
university or Florida College System Institution that I plan to attend.
All other charges/fees are my responsibility.
My ability to secure the courses I request depends on space availability.
NOTE: Participating employees should be aware that the school at which you apply may require you to
provide your social security number to verify employment.
______________________________________
______________________________________
Employee Signature
Date
Agency Authorization
I authorize the above named employee to participate in the Tuition Waiver Program. I also certify that the
above-named employee holds an established authorized position with a full time equivalency (FTE).
Supervisor’s name (please print)
Supervisor’s Signature
Title
Date
Agency Head or designee (please print)
Agency Head or designee Signature
Title
Phone #
Date
09/28/2016
TEMPLATE
Reset/Clear Form
Save As
Print Form