Deceased / Disabled Retired State Employees Tuition Waiver Form printable pdf download

Deceased / Disabled Retired State Employees Tuition Waiver

KRS 164.2841

Must be the child or nonremarried spouse of an employee participating in a state-administered retirement

system who died of a duty related injury. Must provide proof of relationship to the deceased, proof that the

death/disability was duty related and proof of the deceased/disabled employee’s enrollment in a state retirement system.

Full tuition waiver.

KRS 164.2842

Must be the spouse or the child (over the age 17 and under 23) of an employee participating in a state

administered retirement system who was disabled due to a duty related injury. Must provide official proof of relationship

to the disabled person, official proof that the disability was duty related and proof of the disabled employee’s enrollment

in a state retirement system. Full tuition waiver up to 36 months.

Name: ______________________________________________ ID #: _____________________________

Address: _______________________________________________________________________________

City: ________________________________________ State: __________ Zip: ____________________

Date of Birth: ______________________ Semester you plan to enroll at EKU: _____________________

Applicant’s relationship to the deceased / disabled: ____________________________________________

Name and address of employer of deceased / disabled at time of death / disability:

__________________________________________________________

Phone # of employer: ________________________ State Retirement System: _______________________

I authorize the Scholarship Office to verify the above information in order to process this waiver. This waiver cannot be

used concurrently with any other tuition waivers, which includes but not limited to institutional awards, scholarships and

other state mandated, University funded waivers. I hereby state that all information provided is accurate and understand

the knowingly providing incorrect information will void this waiver and all future use of the waiver at Eastern Kentucky

University.

_____________________________________________________

________________________________

Signature of applicant

Date

OFFICE USE ONLY:

Verified By: ___________________________________________ Date: ______________________________

_________ Birth Certificate ________ Social Security Card _________ Documentation of duty related

death/disability

_________ Eligible

________ Ineligible

Created on 5/24/05

Deceased / Disabled Retired State Employees Tuition Waiver Form