Free 49926.PDF - Indiana

INDIANA TUITION REPORT
State Form 49926 (10-00)

TUITION: $

FOR OFFICE USE ONLY BOND AMOUNT: $

EFFECTIVE DATES: FROM: / / REQUIRED BOND AMOUNT: $ INCREASE REQUESTED: (Amount of Increase) $ DEADLINE: / / TO: / /

NOTE: This form must be completed and submitted with an Institutional Surety Bond. If all the information is not provided, the form will be returned to the institution.

YES

NO

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)