Form 49926 - Indiana Tuition Report
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1FOR OFFICE USE ONLY
TUITION:
BOND AMOUNT:
$
$
INDIANA TUITION REPORT
EFFECTIVE DATES:
State Form 49926 (10-00)
FROM:
/
/
TO:
/
/
NOTE: This form must be completed and submitted
REQUIRED BOND AMOUNT:
with an Institutional Surety Bond. If all the information
$
is not provided, the form will be returned to the
INCREASE REQUESTED:
YES
NO
institution.
(Amount of Increase) $
DEADLINE:
STATUS:
/
/
1. Name of School
2. Address (number and street)
City
State
Zip Code
Telephone Number
3. Fiscal Year Ending: (including year)
4. Total Gross Tuition/Instructional fees received from all Indiana residents during the above fiscal year:
$
5.
Total Gross Tuition/Instructional fees received from all out of state residents instructed within Indiana during the
above fiscal year:
$
6. Total Indiana Tuition: (sum of 4 & 5)
$
AFFIDAVIT
I HEARBY SWEAR OR AFFIRM THAT THE ABOVE STATEMENTS ARE TRUE.
____________________________________
(SCHOOL ADMINISTRATOR)
____________________________________
(OFFICIAL CAPACITY)
NOTARY SIGNATURE AND SEAL
SEAL:
STATE OF ______________________
COUNTY OF ____________________
Subscribed and Sworn before me this _______day of ____________,_____.
____________________________________
(Notary Signature)
My Commission Expires:
____________________________________
(Notary Printed Name)
________________,______
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