COLORADO SCHOOL OF MINES
APPLICATION
TM
DEPENDENT TUITION REDUCTION PROGRAM
I. INSTRUCTIONS: Submit this form to Human Resources for each semester of enrollment no later
than the first day of the semester. Applications received after the first day of the semester wil not be
eligible for the benefit.
II. EMPLOYEE INFORMATION (PLEASE TYPE OR PRINT)
Employee Name: ____________________________________________ CWID: ___________________
Campus Phone: ____________________________________ Academic Year: ____________________
Semester: □ Fall □ Spring □ 1st Field □ 2nd Field □ Summer I □ Summer II
Employee’s Department: ___________________________ Email: ______________________
I certify that the dependent named below is my dependent child who is unmarried, has not attained age
24, is chiefly dependent upon me for support and maintenance, meets the I.R.S. definition of a
dependent, and can be claimed as an exemption on my income tax filing. I understand I may be required
to provide proof of dependent status. I agree to notify the Human Resources Office immediately of any
change in status with my dependent. I understand that if any Dependent Tuition Reduction Benefits are
granted for an ineligible dependent, I agree to repay the Colorado School of Mines for any Dependent
Tuition Benefits received for the semester in which the dependent is determined to be ineligible. Further,
I understand that if I knowingly file a request for an individual who does not qualify as an eligible
dependent or otherwise contains any misrepresentation or any false, incomplete, or misleading
information, I may be subject to adverse employment action up to and including termination.
Employee Signature: _________________________________________ Date: ____________________

III. DEPENDENT STUDENT INFORMATION (PLEASE TYPE OR PRINT)
Dependent Student’s Name: ________________________________________ CWID: ______________
Email: _________________________________ Relationship to Employee: ______________________
I understand that in order to be eligible for this Dependent Tuition Reduction Benefit I must remain a full
time undergraduate student and that I must be in “good standing” as defined by the Colorado School of
Mines. I also understand that once I have completed the requirements for an undergraduate degree, the
Dependent Tuition Reduction Benefit wil end regardless of whether I apply for graduation and that the
maximum number of undergraduate hours to which this benefit may apply is 145 credit hours. I
understand that this benefit does not apply to graduate credit hours.
Dependent Student Signature: __________________________________ Date: __________________

For University Use
HR – Eligible employee? Yes □ No □ % Appt: ___ Signature:_______________ Date:
____________
Fin. Aid – Eligible student? Yes □ No □ Signature: _____________________ Date: ____________