Attachment I

Texas State University

Tuition Rebate Program Application

Section A – Student


Submit this completed rebate application to your college academic advising center no sooner than the first day of the semester in which you graduate and no later than the workday immediately preceding your graduation date. Texas law requires students to apply for rebates PRIOR to receiving their baccalaureate degrees and provide current address information for 60 days after graduation.


Name: _________________________________________________            ID#: ______________________

Email: _________________________________________________


Local Address: __________________________ Permanent Address:           ________________________

                       __________________________  (check will be mailed here)  ________________________


Local Phone: ___________________________    Permanent Phone: _____________________________


Semester of Graduation: _________________________


Major (1st):      ________________________________ Minor (1st):_______________________________


Major (2nd):     ________________________________ Minor (2nd):_______________________________


I hereby request a Tuition Rebate, as authorized under the Tuition Rebate Program, in accordance with Texas Education Code 54.0065, for the first baccalaureate degree I have earned. I have been a resident of Texas, as outlined in the Texas Administrative Code, Section 21.24, and entitled to pay resident tuition at all times while pursuing the degree, and will provide appropriate documentation when requested. I understand that the amount of the rebate will not exceed $1,000 and is limited to only those amounts paid by me for Education and General tuition (excluding financial aid). I also agree that the university will first apply the rebate to all outstanding obligations to Texas State University and the State of Texas. Unless I specify otherwise, I agree that the university will forward any rebate I am eligible to receive to my permanent address on file at the university. I authorize Texas State University to access my educational and financial records at other institutions of higher education to determine my eligibility for a Tuition Rebate. I authorize Texas State University to discuss this application with me by telephone or e-mail, using the phone number and e-mail address maintained at the university.

____________________________________________________     _________________________

Signature                                                                                              Date


Section B – College Dean or Supervisor of the College Academic Advising Center


This student’s academic records have been reviewed and, for this program, the student is:


¨  Eligible                               Name and Title: _____________________________________________

¨  Not eligible                         College: ___________________________________________________


____________________________________________________     _________________________

Dean’s or Supervisor’s Signature                                                           Date


Section C – Accounting Office


Reviewed by:

____________________________________________________     _________________________

Signature                                                                                              Date