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Questions about this form? Contact HRS Benefits
E-mail: Fax: 773-834-0996
THE LABORATORY SCHOOLS
EDUCATION ASSISTANCE SUPPLEMENT APPLICATION
FOR FACULTY and CLINICAL FACULTY ONLY
If you are an eligible faculty or clinical faculty member at the University of Chicago, you may be entitled to a subsidy towards the annual tuition cost for each child/dependent attending the University of Chicago Laboratory Schools. This Supplement is in addition to and separate from the Education Assistance Program 50% Tuition Remission benefit.
To apply you must meet ALL of the following criteria:
· Be a full-time faculty or clinical faculty member at the University of Chicago;
· Have child/dependent enrolled at the Laboratory Schools for the current academic year; and
· Have a total annual household adjusted gross income* less than $200,000.
Annual Supplement amount per child/dependent, per academic year, is based on total annual household adjusted gross income as follows:
Total Annual HouseholdAdjusted Gross Income / Annual Supplement Amount
Per Child/Dependent
Less than $75,000 / $600
$75,000 – $99,999 / $500
$100,000 - $149,999 / $400
$150,000 - $199,999 / $300
Greater than $199,999 / $0
* Total Annual Household Adjusted Gross Income includes your income and the income of your spouse or University-
Registered Same-Sex Domestic Partner or Illinois Civil Union Partner.
Please complete this form and return to the Benefits Office, along with a copy of pages 1 & 2 of your most recent Federal Income Tax Return. You may redact all income information on your tax return(s) except for the line showing “adjusted gross income”. If approved, the supplement amount will be included as taxable income on your paycheck. Applications may be submitted 15 days prior to, but no later than 60 days after the Laboratory Schools academic year begins. Please note you must apply each academic year and submit a copy of pages 1 & 2 of your most recent tax returns. Please refer to the Laboratory Schools Education Assistance Supplement policy for details at hrservices.uchicago.edu/benefits/tuition.
Department Name: / Work Phone:
Email Address:
Child/Dependent for whom Laboratory Schools Education Assistance Supplement is being sought:
1. / Child/Dependent Name: / Date of Birth:
2. / Child/Dependent Name: / Date of Birth:
3. / Child/Dependent Name: / Date of Birth:
4. / Child/Dependent Name: / Date of Birth:
5. / Child/Dependent Name: / Date of Birth:
Please attach a separate sheet with additional names and dates of birth, if applying for more than 5 children/dependents.
I hereby apply for reimbursement in accordance with the established “Laboratory Schools Education Assistance Supplement” policy. I have read the policy as stated and understand its provisions. I attest that the information provided above is true and that the attached documents are valid.
Employee Signature: / Date:BENEFITS ONLY:
o Approved / o Denied and Reason:Benefits Staff Signature: / Date:
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