PART I EMPLOYEE INFORMATION EMPLOYEE’S NAME LAST FIRST LAST FOUR DIGITS OF ORGANIZATION DATE M.I. SOCIAL SECURITY NUMBER NUMBER ADDRESS STREET CITY STATE ZIP – PART II COURSE INFORMATION AND COSTS (A) (B) (C) (D) (E) (F) (G) COURSE TITLE AND NUMBER COURSE CREDIT TUITION RATE FINANCIAL TUITION AMOUNT 75% OF TOTAL EMPLOYEE DATES HOURS PER CREDIT PAYABLE BY EMPLOYEE COST ELIGIBLE HOUR or E PER EMPLOYEE PER TUITION COST FOR MAXIMUM CREDIT CREDIT HOUR (C) PER CREDIT REIMBURSEMENT APPROVED HOUR ** (D) HOUR – RATE PER (F) * (B) CREDIT HOUR (E) * (.75) ** 1. 2. 3. 4. 5. TOTAL COSTS TO BE REIMBURSED (may not exceed MAXIMUM APPROVED RATE listed ** See Page 3 for further instructions. on page 3) PART III GRADUATE LEVEL ACCOUNTING USE ONLY Are these costs for a graduate level course? Yes No See Personnel Policy 6504 Assistance” for definition “Educational LINE FUND AGENCY ORGANIZATION APPROPRIATION PART IV CERTIFICATION OF STATEMENT 01 6 0 5 02 6 0 5 I HEREBY CERTIFY THAT THE ABOVE COSTS ARE JUST AND LINE ACTIVITY OBJECT SUBOBJ* AMOUNT NO PART OF THE TOTAL COST TO BE REIMBURSED STATED ON THIS REQUEST HAS BEEN PAID THROUGH OTHER 01 R 8 2 4 2 3 8 6 SOURCES OF FINANCIAL ASSISTANCE. 02 R 8 2 4 2 3 8 6 LINE JOB NO. /PROJECT NO. *If undergraduate course, use 01 01 _--- *If graduate course, use sub-object 02 02 DATE EMPLOYEE’S SIGNATURE _________ ___________________________________________________________ _---_____ DATE CO HR - EMPLOYMENT SIGNATURE DATE SUPERVISOR’S SIGNATURE
PART I EMPLOYEE INFORMATION EMPLOYEE’S NAME LAST FIRST M.I. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER ORGANIZATION NUMBER DATE ADDRESS – STREET CITY STATE ZIP PART II COURSE INFORMATION AND COSTS COURSE TITLE AND NUMBER COURSE DATES (A) (B) CREDIT HOURS (C) TUITION RATE PER CREDIT HOUR or MAXIMUM APPROVED RATE PER CREDIT HOUR ** (D) FINANCIAL PER CREDIT HOUR ** (E) TUITION AMOUNT PAYABLE BY EMPLOYEE PER CREDIT HOUR (C) – (D) (F) 75% OF EMPLOYEE TUITION COST PER CREDIT HOUR (E) * (.75) (G) TOTAL EMPLOYEE COST ELIGIBLE FOR REIMBURSEMENT (F) * (B) 1. 2. 3. 4. 5. ** See Page 3 for further instructions. TOTAL COSTS TO BE REIMBURSED (may not exceed MAXIMUM APPROVED RATE listed on page 3) PART III GRADUATE LEVEL Are these costs for a graduate level course? Yes No See Personnel Policy 6504 “Educational Assistance” for definition ACCOUNTING USE ONLY LINE FUND AGENCY ORGANIZATION APPROPRIATION PART IV CERTIFICATION OF STATEMENT I HEREBY CERTIFY THAT THE ABOVE COSTS ARE JUST AND NO PART OF THE TOTAL COST TO BE REIMBURSED STATED ON THIS REQUEST HAS BEEN PAID THROUGH OTHER SOURCES OF FINANCIAL ASSISTANCE. 01 6 0 5 02 6 0 5 LINE ACTIVITY OBJECT SUBOBJ* AMOUNT 01 R 8 2 4 2 3 8 6 02 R 8 2 4 2 3 8 6 LINE JOB NO. /PROJECT NO. *If undergraduate course, use 01 *If graduate course, use sub-object 02 _--- DATE EMPLOYEE’S SIGNATURE 01 02 _---_____ DATE SUPERVISOR’S SIGNATURE _________ ___________________________________________________________ DATE CO HR - EMPLOYMENT SIGNATURE E
Educational%20Assistance%20Reimbursement%20Request%20and%20Repayment%20Agreement.docx