08/2019
Request for Tuition Waiver or Tuition
Reimbursement
Date:
Name:
Title:
Union Affiliation (if applicable):
Division:
Z#:
Department:
Fund: Org: Program:
Highest Degree:
This request is for:
Matriculated: Yes No
Term:
Tuition Waiver
EducationCertificate
Undergraduate Program
Tuition Reimbursement
Graduate Program
Will you receive any type of financial aid for the course(s) you are requesting? Yes
No
• Employees are eligible for Tuition Waiver or Reimbursement once they have completed one year of employment.
• Graduate tuition waivers in excess of $5,250.00 will be recorded as taxable wages and applicable taxes will be withheld
through payroll payments. Additional tax withholdings can be significant in some cases.
• LEAVE OF ABSENCE: Unless prohibited by law, Tuition Waiver or Reimbursement benefits will cease during a leave of
absence that is one month or longer in duration.
Courses Requested:
Supervisor’s Recommendation: I recommend that the above named employee be authorized to take the
course(s).
Explanation of adjusted workweek, if required:
The above named is authorized to have tuition waived or reimbursed in the amount of $ course(s)
during the term if all requirements are met.
for
Human Resources Rep: Date
Grades verified and approved for payment/waiver.
Human Resources Rep: Date
