REIMBURSEMENT REQUEST
Step 4: TUITION REIMBURSEM ENT
To be completed at END of semester.
Name: _
Department: Title: _
Name of College or University: _
Semester course(s) taken:
Course Title(s)
Tuition Cost
Textbook Cost
l.
2.
3.
Approximate Cost:
Tuition$ _ Books$ _
Did you receive funds from any other source for payment of tuition/textbooks?
__YES __NO
Employees receiving tuition assistance from a source that does not require repayment
(Veteran’s benefits, grants, scholarships, etc.) are required to submit reimbursement
requests for the balance of the tuition not covered by the alternate source.
By signing this request form, I certify that this tuition reimbursement request is a true
and accurate statement of my enrollment, course completion, grade, and tuition/textbook
expense. I am hereby requesting reimbursement pursuant the city's personnel policy.
_
Date
Employee Signature
HUMAN RESOURCE DEPARTMENT: Reimbursement
Human Resource Director Date
Appendix E
Form 9
NOTE: To receive tuition and book reimbursement, the employee must attach a grade report
for a II course(s) indicated, as well as a fee receipt for tuition and textbook payment.
click to sign
signature
click to edit
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