Commonwealth of Massachusetts
Human Resource Division

Tuition Remission Certificate

Section 1 - College/University Information

The State Employee or his/her spouse named below is eligible for tuition remission for
College/University (Required)	Academic Semester (Required)	Academic Year (Required)

Section 2 - State Employee Information

Employee Name (Required)			Employee ID (Required)	Record #
Home Address (Required)			Management Level
Home City (Required)	Home State (Required)	Home Zip (Required)	Collective Bargaining Unit
Preferred Contact Number (Required)	Extension		To avoid delays in delivery, please provide a work or personal email address you wish to receive our completed Tuition Remission Form. If no email address is entered, the form will be mailed to the home/mailing address on file.
Agency (Required)
Agency Address			Email Address
Agency City	Agency Zip		Confirm Email Address
Eligible Student (Required)	Spouse Name (Required)		Browse Marriage Certificate

Section 3 - Voluntary Information (Optional)

Gender

Male

Female

Person with Disability

Yes

No

Military Status (Check all that apply)

Active Reserve	Desert Shield Veteran	Iraq Veteran	Operation Iraq Freedom Veteran
Inactive Reserve	Desert Storm Veteran	Operation Enduring Freedom Veteran	Other Protected Veteran
Afghanistan Veteran	Disabled Veteran

Are you Hispanic or Latino?
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race

Yes

No

Race (Check all that apply)

	American Indian or Alaska Native
	A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.
	Asian
	A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
	Black or African American
	A person having origins in any of the black racial groups of Africa.
	Native Hawaiian or Pacific Islander
	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
	White
	A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Primary Ethnic Group (Select one)

Hispanic or Latino	American Indian or Alaska Native	Asian
Black or African American	Native Hawaiian or Pacific Islander	White	No Primary

Employee Acknowledgement Section

By selecting this checkbox you certify that you have read and understand the tuition remission guidelines (Required). Read guidelines link
By selecting this checkbox you certify that the information in this form is truthful and accurate (Required)
Employee Name (Required)		Submission Date

Employee Signature	X

Section 4 - ESC Specialist Verification of Eligibility

Employed Full Time (Required)		Validation of proof of marriage	Entry date to state service (M/d/yyyy)
Agency Code		Position Number	Date completed 6 months of service
ESC Specialist			ESC Specialist phone number

Section 5 - ESC Signatory Approval

ESC Approver Title		ESC Approver Phone
ESC Approver		Approval Date
By selecting this checkbox you certify that the information in section 4 is truthful and accurate.

CERTIFICATE VALID FOR 120 DAYS FROM DATE OF ISSUE BY SIGNATORY AUTHORITY