Instructions: The following information must be completed by the student each academic year, and sent to the Office of Student Financial Aid where the student will be attending. For addresses, see attachment.

Student Name:_____________________________Birth Date:____________University ID #:__________________

Street Address:_________________________________________________Local Phone #:___________________

City/State/Zip Code:_____________________________Academic Term: FA_____ SP_____ SU1_____ SU2 ______

This application is for the 50% Child of Employee Tuition Waiver to be used at: _______________________________

Major:______________________________________ Expected Graduation Date:___________________________

Have you used the 50% Child of Employee Tuition Waiver benefit at ANY campus of the following universities?

(Chicago State University, Eastern Illinois University, Governors State University, Illinois State University, Northeastern Illinois University, Northern Illinois University, Southern Illinois University, University of Illinois, or Western Illinois University.)

University academic terms during which the 50% tuition waiver benefit was utilized:

Name of University:____________________________________________ Semester/Year: ______________

I hereby declare that all previous or concurrent academic terms, during which the 50% Child of Employee Tuition Waiver benefit was utilized, are accurately accounted for above. I request and understand that this information may be verified by means of accessing university records and that the total 50% Child of Employee Tuition Waiver benefits granted to me may not exceed the 4-year limitation established in P.A. 90-0282. A separate “Tuition Waiver Benefit Utilization Record” (B.U.R.) must be completed by the student where he/she is currently enrolled, pursuant to P.A. 90-0282.

Student Signature: ____________________________________________ Date: ______________________

www.osfa.uiuc.edu finaid@uiuc.edu For faster service! fax (217) 265-5516

TUITION WAIVER BENEFIT UTILIZATION RECORD
(B.U.R.)
Attachment
Public Act 90-0282

Contact List for University of Illinois Campuses

University of Illinois at Chicago

Employee Contact: Student Contact:

Academic Human Resources/Records Student Financial Aid Office

400 HRB, 715 South Wood, MC-900 1800 SSB, MC-334

Chicago, IL 60612 Chicago, IL 60607

(312) 413-3490 Fax: (312) 996-1803 (312) 996-3126 Fax (312) 996–3385

http://www.uic.edu

University of Illinois at Springfield

Employee Contact: Student Contact:

Department of Human Resources Office of Financial Assistance

HRB 30, UIS, P.O. Box 19243 SAB 60, P.O. Box 19243

Springfield, IL 62794-9243 Springfield, IL 62794–9243

(217) 206-6652 Fax: (217) 206-7145 (217) 206–6724 Fax (217) 206–7376

http://www.uis.edu/financialaid/

University of Illinois at Urbana - Champaign

Staff Employee Contact:

Personnel Services Office

52 East Gregory MC-562

Champaign, IL 61820 Student Contact:

(217) 333-2142 Fax: (217) 244-7304

Office of Student Financial Aid

620 East John Street, MC-303

Faculty and AP Employee Contact: Champaign, IL 61820

(217) 333–0100 Fax (217) 265-5516

Academic Human Resources http://www.osfa.uiuc.edu

807 S. Wright Street – Suite 420, MC-310

Champaign, IL 61820

(217) 333-8836 Fax: (217) 333–4019

FOR OFFICE USE ONLY: 50% tuition waiver benefit utilization record confirmation (optional as requested by the tuition waiver granting institution): In accordance with institutional standards for tuition waiver benefit utilization, the record outlined above is correct.

Name: _____________________________________

Authorized signature of record confirmation by the Financial Aid Office Date

www.osfa.uiuc.edu finaid@uiuc.edu For faster service! fax (217) 265-5516

Contact List for University of Illinois Campuses

FOR OFFICE USE ONLY: 50% tuition waiver benefit utilization record confirmation (optional as requested by the tuition waiver granting institution): In accordance with institutional standards for tuition waiver benefit utilization, the record outlined above is correct.

Name: _________________________________________________________ ____________________

Authorized signature of record confirmation by the Financial Aid Office Date

www.osfa.uiuc.edu finaid@uiuc.edu For faster service! fax (217) 265-5516

Contact List for University of Illinois Campuses

Name: _____________________________________