Tuition Waiver Program Dependent Certification Form

Tuition Waiver Program

Dependent Certification Form

Student Information

This form is used only for eligible dependents. Dependent children refers to unmarried sons, daughters,

stepchildren and legally adopted children of the employee or domestic partner claimed as dependents on

the most recent federal tax return. (A Domestic Partner Certification Form must be on file with Human

Resources). Dependent children must remain as dependents during their entire course of study. This form

should be submitted each time a Tuition Waiver Form is submitted.

In accordance with the Northeastern University Tuition Waiver Program Guidelines, I hereby certify that the

student named below is:

☐ My unmarried son, daughter, stepchild, or legally adopted child and this student was claimed as a

dependent on my most recent federal tax return.

☐ The unmarried son, daughter, stepchild, or legally adopted child of my domestic partner and this student

was claimed as a dependent on the most recent federal tax return of my domestic partner. A

Domestic Partner Certification Form must be on file with Human Resources

☐ My unmarried son, daughter, stepchild, or legally adopted child who otherwise meets the definition of

dependent, but who is not listed as a dependent on my most recent federal tax return due to a domestic

relations order.

Dependent children must remain as dependents during their entire course of study. Once a dependent

reaches age 24, you will be required to submit a copy of your most recent federal tax return verifying

the dependent status of this student each time a Tuition Waiver Form is submitted.

Upon request, I agree to provide a copy of the most federal tax return verifying the dependent status of

this student to HR (Benefits), or, if applicable, a copy of the domestic relations order verifying the

dependent status of the student. I also certify that I have read the Tuition Waiver Program Guidelines.

______________________________________________ _______________________

Employee’s Signature Date

Academic term: _________________________________ Academic Year: ______________

(Fall, Winter, Spring, or Summer)

Student’s Name: ________________________________ Student’s NUID: ______________

Student’s Date of Birth: ___________________________

Employee’s Name: _______________________________ Employee’s NUID: _________________

Department: _________________________ Phone Number: ___________________

Forms will be reviewed for completeness and eligibility. You will be notified if any additional information is

needed. Mail completed Dependent Certification Form and Tuition Waiver Form to Human Resources

250 Columbus Place or fax to 617-373-7610. All waivers must be received by HR within 30

days of the course start date.