graduate-assistant-funding-and-tuition-and-fees-designation-form-1

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