Application for Dependent Education Program
Last Revised: 08/02/04

Applying for: Fall Semester____ Spring Semester ____as a: New Enrollment______ Re-Enrollment_________

Name:_________________________________________ Social Security Number:____________________________

UNM Department: ___________________________________Campus Phone:_______________________________

E-mail address: ______________________________________Home Phone: ________________________________

Name:________________________________________________ Social Security Number:_____________________

Relationship to Employee: _________________________________________________________________________

I grant permission to The University of New Mexico to release information concerning my present and future eligibility for this award, including my enrollment status and whether my cumulative GPA is below 2.0 to the employee identified above.

Signature of Dependent ________________________________________ Date: ____________________

A. Child's Date of Birth: __________________ Age: ________________

B. Child's Marital Status: Married____________Unmarried___________

C. Will you (or your ex-spouse) claim the dependent child on your income tax return during the calendar year in which the benefit is received? Yes______ No______

I certify that the information provided above is true and accurate to the best of my knowledge. I understand that the value of the dependent education waiver may be taxable.

Signature of Employee __________________________________________ Date: ___________________
Please keep a copy for your records.

DEPENDENT EDUCATION PROGRAM

• Return application form to the Department of Human Resources, Employee Benefits Office by the announced deadline (address listed below).
  
  
• Employees are eligible if they are regular, full-time staff or faculty members for at least one year by application deadline.
  
  
• A qualified dependent is a legal spouse of the employee or a natural, legally adopted, or step child who is unmarried and less than 25 years of age at the time of application.
  
  
• The dependent must be admitted to UNM on regular status prior to the Program application deadline. The benefit is for undergraduate education only. Dependents who have attended The University of New Mexico must have a UNM GPA of 2.0 at the time of application.
  
  
• The tuition benefit will NOT cover tuition for the summer semester; this application covers tuition for the Fall and Spring semesters, and will extend for up to eight (8) consecutive semesters or until the degree requirements for which the benefit was awarded are met, whichever occurs first. The benefit amount will not include mandatory student fees which are charged by the credit hour.
  
  
• An employee whose domestic partner participates in the program or whose child meets any of the taxability criteria listed in the policy, will have the value of the tuition benefit included as compensation on the W-2 form filed with the IRS, according to IRS regulations. The tax withholding amount will be deducted once per semester.
  
  
• For more information, refer to the "Dependent Education Program" Policy 3785, UBP found in the University Business Policies and Procedures Manual.
  
  

UNM Human Resources Service Center
1730 Lomas Blvd. NE
Albuquerque, NM 87131

  Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm