Form 36800 Available at: h p://www.hr.umich.edu/hrris/forms/pdfs/tui onsupportrequest.pdf
Revised 5/11
First Name:
Middle Name:
UMID: Department:
If yes, source and amount:
Ins tu on you plan to a end:
How is this course work related to your job or career objec ves at the University?
Last Name:
Procedures stated in the Tui on Support SPG 201.69 must be followed to allow payment of the request. If you must have
approval of this request before registering, this form must be submi ed to your supervisor at least 20 University business
days before registra on. Be sure to give all informa on requested. Please keep a copy of this form for your records.
PERSONAL INFORMATION
Credit Hours:
Classifi ca on Title:
Date of Hire (Service Date):
Full-Time
Part-Time
Appointment Frac on:
Degrees Received:
Yes
No
Eligible for Veterans Benefi ts:
Yes
No
Eligible for Scholarships:
Course Name:
Course Number:
Undergraduate
Graduate *
Final Grade:
Credit Hours:
Course Name:
Course Number:
Undergraduate
Graduate *
Final Grade:
If a degree program, give degree, area of specializa on and how course is related to the degree (required, elec ve, etc.)
Tui on and Registra on Fees: $ _________________ (Not to include applica on fees, lab fees, books or other materials.)
Yes
No
Tui on Reimbursement:
Yes
No
Tui on Advance:
If Tui on Advance, date course ends: _______________
Date and amount of Tui on Support Payments
received this calendar year (Jan 1-Dec 31).
I hereby cer fy the above informa on is correct, that I qualify for support under the Tui on Support Program at the University of Michi-
gan as set forth in SPG 201.69 and that I have declared (above) any other sources from which tui on support could be obtained. Where
a tui on support payment is paid in advance, and in the event I do not successfully complete the course (as defi ned in sec on II.A.) or do
not provide the required documenta on in a mely manner (as set forth in sec on II.G.), I authorize the Payroll Department to deduct
the full amount of the tui on advance from my future paycheck(s). Deduc ons may be taken over a maximum six-month period, and no
addi onal Tui on Advances will be paid un l all deduc ons have been processed. I further understand that if I leave the University be-
fore successfully comple ng the course, or before providing the required grade report and paid bill or receipt to my supervisor, or before
reimbursing all amounts owing under this policy, I am obligated to repay the full amount of the advance to the University immediately. If
I have not done so before my last day at work, I authorize the University Payroll Offi ce to deduct the full amount owing under this policy
from any remaining regularly scheduled paychecks to the extent permissible by law and understand that I remain liable for any balance.
NOTE: Tui on reimbursements for Graduate Studies are subject to taxa on. Please see SPG 201.69-0 for current amounts.
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Date: Amount:
Date: Amount:
Employee Signature:
Date:
TUITION SUPPORT REQUEST
Form
36800
