Indiana State Form 51804 – Fill Out and Use This PDF

CAREER COLLEGE STUDENT ASSURANCE FUND	FOR OFFICE USE ONLY
QUARTERLY COLLECTION (CCSAF-1)	Date stamp upon receipt (month, day, year)
State Form 51804 (R2 / 6-11)
Approved by State Board of Accounts, 2011

INSTRUCTIONS: 1. Please print legibly or type the information on this form.

2.A separate form is required for each campus location.

3.Payment is due forty-five (45) days from the close of the quarterly reporting and collection period.

4.Send the completed form and FUND payment to the Indiana Commission on Proprietary Education, 302 West Washington Street, Room E201, Indianapolis, Indiana 46204.

5.If you have any questions concerning this form, please contact the Commission at (317) 232-1320.

SECTION A - REPORTING INFORMATION

1.	COPE advertising code		2. Reporting quarter (check appropriate box)			July 1 - September 30				3. Year of reporting quarter
			January 1 - March 31	April 1 - June 30		October 1 - December 31
4.	Name of contact person (person responsible for completing this form)						5. Daytime telephone number
							(	)
			SECTION B - OWNER INFORMATION
1.	Name of owner (legal, partnership, corporate, or other entity name)
2.	If sole owner (last name, first name, middle initial, suffix)
3.	Primary address (number and street, city, state, and ZIP code)
4.	E-mail address
			SECTION C - CAMPUS INFORMATION
1.	Business trade name / DBA
2.	Physical address (number and street, city, state, and ZIP code - no PO Box numbers)
3. Telephone number of business location					4. Fax number of business location
	(	)			(	)
			SECTION D - REPORT OF QUARTERLY EARNED TUITION
	1. Total Gross Tuition / Instructional fees received from all Indiana residents this quarter:
	2. Total Gross Tuition / Instructional fees received from all out of state residents instructed within Indiana this quarter:
	3. Total value of refunds made this quarter (to students from, or instructed in, Indiana):
	4. Net tuition earned (Lines D1 + D2 - D3):
			SECTION E - CALCULATION OF REQUIRED CONTRIBUTION
	1. Required FUND Contribution (0.1% Net Tuition; Line D4 X .001):
	2. Additional Required Fee (IC 21-17-3-9):									$60.00
	3. Total Payment this quarter (Lines E1 + E2):
			SECTION F - SIGNATURE AND CERTIFICATION OF NOTARY PUBLIC
	STATE OF _______________________________
			SS:
	COUNTY OF _____________________________
	I, ________________________________________________________________, first being duly sworn on oath say that I am the above named,
	that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of person completing this form							Date subscribed and sworn (month, day, year)
Printed or typed name of person completing this form
Signature of notary public					Printed or typed name of notary public
County of residence					Date commission expires (month, day, year)

INSTRUCTIONS FOR COMPLETING STATE FORM 51804, CAREER COLLEGE STUDENT ASSURANCE FUND QUARTERLY COLLECTION (CCSAF-1)

INSTRUCTIONS FOR COMPLETING STATE FORM 51804 & SUBMITTING PAYMENT TO THE FUND

All sections of the form must be completed.

Purpose: The career college student assurance fund is established to provide indemnification to a student or an enrollee of a postsecondary proprietary institution who suffers loss or damage as a result of any of the occurrences described in section 5(c) of IC 21-17.

State Form 51804 is used to calculate and process quarterly payments to the Career College Student Assurance Fund as directed under IC 21-17-3-9 and 570 IAC, the statute and regulations of the Indiana Commission on Proprietary Education.

This form and the required payment must be submitted quarterly in accordance with IC 21-17-3-9 and 570 IAC 1-14.

A completed form and payment is required of each campus for which a surety bond is required for accreditation.

Section D (Report of Quarterly Earned Tuition) pertains to all students who are residents of Indiana - regardless of instructional location - and all students instructed within the state of Indiana. The annual (four-quarter) totals from Line D1 and Line D2 should be comparable to the values reported on the Indiana Tuition Report (State Form 49926).

Payment of the Additional Required Fee (Line E2) is required every quarter as defined in IC 21-17-3-9 et seq. If no tuition revenue is collected, or if the FUND has reached maturity, please remit ONLY this amount.

Failure to remit the appropriate fee(s) may result in the suspension or revocation of institutional accreditation to operate as a postsecondary proprietary institution within the state of Indiana.

Be sure to answer all applicable questions. Failure to do so may result in delays in crediting your account. Please print legibly or type the information on your application.

Payment is due forty-five (45) days from the close of the quarterly reporting and collection period.

Send the completed form and payment to the Indiana Commission on Proprietary Education, 302 West Washington Street, Room E201, Indianapolis, Indiana 46204.

If you have any questions concerning this form, please contact the Commission at (317) 232-1320.

LAWS & REGULATIONS REGARDING CONTRIBUTIONS TO THE CAREER COLLEGE STUDENT ASSURANCE FUND

STATUTORY AUTHORITY & AGENCY REGULATIONS REGARDING CONTRIBUTIONS TO THE CAREER COLLEGE STUDENT ASSURANCE FUND

(Full texts of the Indiana Code and Indiana Administrative Code are available on the Commission’s web site, www.in.gov/cope.)

IC 21-17-3-9 Quarterly contributions to fund; determination; bond

Sec. 9.3. (a) Subject to section 9(a) of this chapter, each postsecondary proprietary educational institution shall make quarterly contributions to the fund. The quarters begin January 1, April 1, July 1, and October 1.

(b)For each quarter, each postsecondary proprietary educational institution shall make a contribution equal to the STEP THREE amount derived under the following formula:

STEP ONE: Determine the total amount of tuition and fees earned during the quarter.

STEP TWO: Multiply the STEP ONE amount by one-tenth of one percent (0.1%).

STEP THREE: Add the STEP TWO amount and sixty dollars ($60).

(c)Notwithstanding section 6 of this chapter, for a postsecondary proprietary educational institution commencing operation after

September 30, 2004, the commission, in addition to requiring contributions to the fund, shall require the postsecondary proprietary institution to submit a surety bond in an amount determined by the commission for an amount of time that represents the number of quarters required for the fund to initially accumulate one million dollars ($1,000,000) as determined under section 6 of this chapter.

570 IAC 1-14 Career College Student Assurance Fund

570 IAC 1-14-3 Fund contributions

Sec. 3. (a) The proper amount of a postsecondary educational institution’s fund contribution shall be calculated in accordance with IC 21-17-3-9.

(b)Upon receipt of a contribution from a school to the fund, the check shall be deposited into the fund within twenty-four (24) hours of receipt.

(c)Money in the fund not currently needed will be invested by the treasurer of the state.

(d)The treasurer of the state shall invest the money in a manner similar to the investment of other public funds.

(e)Any gains made from fund investments shall also be deposited into the fund.

(f)Fund proceeds do not revert into the general state fund.

570 IAC 1-14-4 Quarterly contributions

Sec. 4. Each postsecondary proprietary institution shall make quarterly contributions to the fund in compliance with IC 21-17-3-9. As used in IC 21-17-3-9, “total amount of tuition and fees” means gross income before depreciation, taxes, or amortization, less any student refunds required by this rule or by student contract.

570 IAC 1-14-5 Quarterly beginnings

Sec. 5. A new quarter will begin on each of the following dates:

(1)January 1.

(2)April 1.

(3)July 1.

(4)October 1.