Fillable Application For Colgate Higher Education Grant Form printable pdf download

APPLICATION FOR COLGATE HIGHER EDUCATION GRANT

This form is to be completed by the eligible Colgate faculty or staff member and submitted to the Human

Resources Department. Separate applications must be submitted for each child attending an accredited college

or university.

Employee’s Name ____________________________________________ Date of Hire_______________________

Title________________________________________________________ Department _______________________

Student’s Name __________________________________________________ Date of Birth _____________________

Name of Institution _____________________________________________________________________________

City/State/Zip Code_____________________________________________________________________________

Sophomore

Junior

Senior

Academic level to be covered by this application:

First Year

This application is for (check one and fill in the appropriate year):

Dates of Attendance for Current Year

Academic Year

________________________________

Less than a full year

________________________________

During the period that the Colgate Higher Education Grant will be received (if granted), the student described above (check

one):

will be my dependent for federal income tax purposes throughout such period.

will not be my dependent for federal income tax purposes throughout such period.*

*If the child does not qualify as a dependent child under the Internal Revenue Code, the value of this benefit will be taxable

to you. The tax will normally be withheld from your paycheck as follows: Fall semester: September – December; Spring

semester: February – May.

Employee Certification:

I certify that (1) the student described above is either my natural child, my adopted child, or my dependent stepchild, and (2) the

information that I have provided on this application form is accurate. I understand that, as a condition of my receiving a Colgate

Higher Education Grant ("Grant"), Colgate has the right at any time to request any information and/or documentation regarding my

child as Colgate may, in its sole discretion, determine to be appropriate to review the child’s eligibility and/or the tax status of any

grant provided with respect to the child. I agree that my eligibility for a Grant shall be subject to the terms of Colgate's Higher

Education Grant Program for Children of Employees. I understand that misrepresentation of any statement on this form, or failure

to provide required documentation in a timely manner, is cause for cancellation of the Grant, and will result in Colgate having the

right, in its discretion: (a) to either issue me a bill for the full costs of the Grant provided, or issue me a corrected Internal Revenue

Service Form W-2 to reflect any additional gross income that I may have as a result of receiving the Grant; and/or (b) to take any

other steps permitted by Colgate's employment policies or by law to address such misrepresentation or failure (including, in certain

circumstances, the termination of my Colgate employment). I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS

OF THE STATE OF NEW YORK THAT THE FACTS CONTAINED IN THIS FORM, AND THE INFORMATION THAT I PROVIDE

IN ANY RELATED DOCUMENTS, ARE TRUE AND CORRECT.

Signed (eligible employee) _____________________________________Date____________________

Please send the completed and signed form to the Human Resources Department.

Eligibility certified by __________________________Date _________________Comments__________________________

Revised 4/1/2015

Application For Colgate Higher Education Grant Form

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