EMPLOYER TUITION REIMBURSEMENT DEFERRED PAYMENT PLAN
STATEMENT OF FINANCIAL RESPONSIBILITY
Student Name:
Student ID:
Phone:
Email:
Terms and Conditions
I understand that for me to be eligible for the Employer Tuition Reimbursement Payment Plan
(ETR) option, I must be in good financial standing with ITU.
Payment in full for the amount deferred is due to ITU no later than six weeks from the official last
day of the trimester, as stated in the ITU’s Academic Calendar. (See http://itu.edu/university-
calendar/) Any unpaid balances will be assessed $100 Late Payment Fee.
ITU cannot accept responsibility, nor extend deadlines, for late payments resulting from delays on
my employer’s behalf. If delays should occur, I must make payment in full and await my
employer’s reimbursement. If the employer, for some reason, refuses to reimburse me, I shall remain
responsible for the full payment of all charges.
STRF only applies to the portion of tuition and fees not reimbursed by my employer (please refer to
section “IV. Student Tuition Recovery Fund Payment” of your Enrollment Agreement).
ITU will not correspond with my employer. I am responsible for submitting an invoice and grade
report to the employer for reimbursement in a timely manner. However, ITU may contact the
employer for employment verification.
I understand this deferment covers only the percentage of tuition and fees that are being paid for by
my employer, and that all other charges are due at the time of my registration.
I will be unable to register for future terms or receive transcripts until the balance is paid in full.
I release my rights under the Family Educational Right & Privacy Act (FERPA) and agree to allow
ITU to release my financial information or to contact my employer for employment verification.
Term (Check One): Academic Year _____________
o Spring Trimester
o Summer Trimester
o Fall Trimester
By signing below, I agree to the terms and conditions set forth in this statement.
Student Signature:
Date:
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EMPLOYER TUITION REIMBURSEMENT DEFERRED PAYMENT PLAN
APPLICATION FORM
TO BE COMPLETED BY STUDENT:
Student Name:
Student ID:
Telephone:
Email Address:
Term (Check One): Academic Year _____________
o Spring Trimester
o Summer Trimester
o Fall Trimester
Estimated Total Cost for the Trimester:____________
TO BE COMPLETED BY EMPLOYER:
By signing this document, the employer confirms that a reimbursement plan is available to the above listed
employee/student. Upon completion of the coursework, the student is responsible for making payment to ITU.
Company Name:
Company Address:
HR Officer’s Name:
HR Title:
Telephone No. :
Please check the space next to the appropriate reimbursement level for the trimester named above:
o Full reimbursement at 100%
o Partial reimbursement at ______%
o Amount $_________
Authorized Employer Signature ________________________ Date ____________
I understand that I am responsible for the payment of all charges no later than six weeks from the official
last day of the trimester, whether or not I am reimbursed by my employer.
Student Signature ____________________________________ Date__________________
FOR ITU USE ONLY:
APPROVED BY: ______________________________________ DATE: _________________
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