Fill and Sign the Form 1041 N Rev January 2005 Fill in Capable Us Income Tax Return for Electing Alaska Native Settlement Trusts

Rhode Island Council 94 (rev. 8/16/05) American Federation of State, County, and Municipal Employees, AFL-CIO 1179 Charles Street, North Providence, RI 02904 Telephone: (401) 724-5900 or (401) 421-9383 Fax: (401) 724-2060 TUITION REIMBURSEMENT APPLICATION Employees within a Council 94 bargaining unit may apply to have the cost of tuition and required books reimbursed for approved courses taken at approved accredited colleges, universities, trade schools, or continuing adult education programs. Reimbursements shall not exceed $600 per semester for a total not to exceed $1200 per fiscal year/per employee. Courses must be job related or required as part of a job-related degree program and may not be taken during scheduled working hours. The employee must receive at least a Grade C for undergraduate courses and a Grade B for graduate courses. Requests to take courses under this program must be presented in advance to the agency Director’s designee who will either approve or deny the application in accordance with the rules outlined above. Instructions: Submit this application to your Director’s designee before taking a course. Prior approval is necessary. Upon completing the course and receipt of your grades, submit a copy of your grades, receipt for your tuition expense, receipt for books purchased for the course, and a copy of the canceled check to the designee. The receipts and canceled check must be copies front and back. (This is not an application for Incentive Credit. To obtain Incentive Credit, you must complete a Request for Incentive Credit form in accordance with established guidelines and procedures.) Name: ____________________________________ Department:______________________________ Address: __________________________________ Division: ________________________________ __________________________________ Classification: ____________________________ Work Telephone No: ________________________ Local: ___________________________________ State Seniority Date: ________________________ College/School: ___________________________ Degree Program: ___________________________ Major/Minor:_____________________________ Course: ___________________________________ Graduate: □ Course Dates Start: ________________________ Completion: ______________________________ __________________________________ Applicant’s Signature Undergraduate: □ ____________________________ Date ……………………………………………………………………………………….. Supervisor/Administrator’s Recommendation: Approved ______ Denied ______ Print Name: _____________________________ Title:____________________________________ ……………………………………………………………………………………….. Director’s Designee: Approved:__________ Denied:__________ Account No.____________________ _______I certify that this course has been determined to be unrelated to the job but, for the purposes of tuition reimbursement, is related to the degree program as allowed by Article 44 of the Council 94 Master Contract and, therefore, is taxable to the employee. _______I certify that this course has been determined to be job related; and, therefore, is non-taxable to the employee. Print Name: _______________________________ Title: ___________________________________ Signature: _________________________________ Date: ___________________________________ Upon submission, a copy must be faxed to Council 94. Once paid, the agency must send a confirmation letter to Council 94 informing them payment was issued (see form letter).