Graduate Assistantship Tuition and Fees/Health Insurance Designation Form Fall/Spring 2021-2022 (202210-202220) THIS IS A: Change in account W Number Change in Hours Last Name W College Middle Name Department Other: First Name Completed By STIPEND SOURCE Acad Affairs Base (URDM)Mentoring AA LIFE (URDM)WGE - Women in Grad Ed SOURCE OF FUNDS FOR TUITION AND FEE REDUCTION Fall (202210) – insert old account used and type “old” next to it / insert new account to be used and type “new” next to it If using same acct string, disregard Dept/Other: Other Half GA - Up to Credits Full GA - Up to Credits Other Half GA - Up to Credits Full GA - Up to Credits SOURCE OF FUNDS FOR STUDENT HEALTH INSURANCE, DEPARTMENTAL, OR OTHER FEES Full GA Remarks Optional Fee Package (only select if student will be submitting the optional student fee pkg petition – this is a cost to the unit/funding source.) Optional Fee Package (only select if student will be submitting the optional student fee pkg petition – this is a cost to the unit/funding source.) List all Account Number(s)/Grant ID(s) Fall (202210) Spring (202220) ½ GA Other Credit Hours Amount(s) Spring (202220) Phone Account Number(s)/Grant ID(s) Date Domestic Fall SHI Other $ Other $ Domestic Spring SHI Other $ Other $ Amount(s) International Fall SHI Remarks International Spring SHI Revised 7-2021 PAYROLL FUNDING (when using multiple funding sources, total percent must total 100%) Effective Date Percent Entity Account Fund Code Fund Source Organiza tion Expense Class Program Activity Future Project Task TOTAL STIPEND ADDITIONAL COMMENTS SIGNATURES Completed By Office of Graduate Education Date Cost Center Approver (signature) Date Date Revised 7-2021