Fill - Free fillable Form 5: RESOLUTION REQUEST FORM NO. 19 (Warren County) PDF form

RESOLUTION REQUEST FORM NO. 19

Application for Approval to Enroll in Job-Related Courses by Employee

1. Name: _____________________________________

2. Position: _____________________________ 3. Department: ____________________________

(attach job description)

4. Course Title: ___________________________________________________________________

5

. Institution or School: _____________________________________________________________

6. Please explain how this course relates to your current position (attach course description):

_______________________________________________________________________________

7. Starting Date: _________________________ 8. Completion Date: _______________________

9. Cost (attach documentation): _______________________________________________________

10. Employee Signature: __________________________________ Date: _________________

11. Supervisor Comments (Approve/Deny)

Supervisor Signature: __________________________________ Date: _________________

12. Department Head Comments (Approve/Deny) Is funding in the department budget? (Yes/No)

Department Head Signature:_____________________________ Date: _________________

13. Human Resources Comments (Approve/Deny)

Human Resources Signature: ____________________________ Date: _________________

14. Committee Recommendation (Approve/Deny)

Committee Chair Signature:______________________________ Date: _________________

If approved by Committee, and resolution approving the course is adopted by the Board of Supervisors, candidate may enroll and

b

e eligible for up to 50% reimbursement for costs in number 9 above. Employee must complete the course with at least a grade of

C, its equivalent, or better. Employee then submits a Tuition Reimbursement Voucher with receipts verifying costs as listed and a

copy of their final grade.

FORM REVISED 2/2/2018

HOW TO USE THIS FORM

1. All requests must be approved by the Board of Supervisors prior to the start date of your class.

2. Complete sections 1 – 10 on the front of this form. Once complete, forward to your immediate

supervisor for review. When forwarding please be sure to include your job description, the course

description from the course catalogue, along with documentation for the amount you are

requesting. If you report directly to a Department Head, skip No. 11 and forward your request

directly to you Department Head for review.

3. Department Heads will review request and forward the form to Human Resources for review

regardless of whether they approve or deny the request

.

4. Human Resources will review request and forward to the Committee Chair for review regardless of

whether they approve or deny the request.

5. Oversight committee will review the request and determine if they would like to move the request

forward to the Personnel Committee.

6. If Personnel Committee approves, a resolution will go to the Board of Supervisors to approve.

Once the Board of Supervisors passes a resolution for your reimbursement, you will receive the

Warren County Tuition Reimbursement Voucher along with instructions on how to submit

documentation for reimbursement once you’ve completed your class.

F

ORM REVISED 2/2/2018

Instructions for Reimbursement of Approved Job Related Course(s)

Congratulations on completion of your Job Related Course! Below are some instructions to assist you in

getting your reimbursement in a timely manner.

T You must have actually paid for your tuition prior to reimbursement.

T Make sure the Warren County Tuition Reimbursement Voucher is completely filled out and

signed. The ‘Course/Book Titles’ column should be a title or description of the course, fees, or

books that you have paid for. The ‘Total Costs’ column is the total amount of the

tuition/fees/books charged by the college or bookstore. The ‘Financial Aid/Scholarships’ column

should include all monies given to you that you are not required to pay back. The difference

between ‘Total Costs’ and ‘Financial/Aid Scholarships’ is the ‘Total Out of Pocket Cost to

Employee’. The amount you will be reimbursed should be listed in the ‘50% reimbursement’

column. If you are filling out this form online the formulas should do the computations for you.

T You must provide a copy of your final grade(s) for th

e course(s) showing a grade of ‘C’ or better.

T You must provide a statement from the college showing the total cost for your tuition, fees, and

books as well as all payments applied to your account. Invoices or billing statements that do not

show payments are not acceptable. Books may be purchased from outside sources, but an

itemized receipt showing the title and cost of the book must be submitted.

T Any ‘free money’ should be listed in the ‘Financial Aid/Scholarships’ column. ‘Free money’ is

anything that you do not have to pay back. This figure does NOT include student loans or credit

card payments.

T Reimbursable fees are only those fees that are showing on your receipt as paid to the college.

Personal internet fees, mileage, etc are NOT considered reimbursable fees.

T Keep in mind that the amount on the resolution is a ‘Not to Exceed’ amount. That means that

you may not necessarily qualify for a reimbursement of that total. Also, if your qualifying

amount is greater than the NTE amount you will not be paid more than the NTE amount unless

your department head gets a new resolution.

F

ORM REVISED 2/2/2018

Reso #

Code(s):

Vendor #

Employee Name

A

ddress

Course/Book

Total Out of Pocket

50% Reimbursement

Titles

Cost to Employee

-$ -$

I, _______________________________, certify that the above reimbursement in the amount of $___________________ is true

and correct; that I have adhered to the Warren County Job Related Course Policy and that I am entitled to the above

reimbursement amount.

Approval for payment:

D

epartment Approval

Approved by:

This claim is approved and ordered paid from the

appropriations indicated above.

Date Signature Date Warren County Auditor

Warren County Tuition Reimbursement Voucher

Warren County Municipal Center

1340 State Route 9

Lake George, New York 12845

Employee Signature

Tax Exempt No. 14-6002576

Department:

Purchase Order No.

Total Costs (Including Fees)

Total Reimbursement Amount



Financial Aid/Scholarships

FORM REVISED 2/2/2018

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