Tuition Reimbursement Request Form

TUITION REIMBURSEMENT REQUEST FORM

Use this form to request reimbursement for tuition and related course expenses in accordance with institutional tuition reimbursement policy. Complete all sections, attach required documentation, and retain copies of receipts and official grade or completion verification. Submission does not guarantee approval; reimbursements are subject to budgetary limits, eligibility criteria, and receipt of required documentation.

Student / Employee Information

Date of Birth:    Student / Employee ID:

Course / Program Information

Course Number / Section:    Credit Hours:    Program / Degree:

Course Start Date:    Course End Date:

Cost Breakdown

Tuition: $    Mandatory Fees: $    Books / Materials: $

Payment Method Requested:

Authorization / Pre-Approval

Is pre-approval required for this course under institutional policy? Yes No

Department / Budget Code:    Date of Verbal Approval:

Eligibility, Conditions, and Certifications

By submitting this request I certify that the information provided is true and complete to the best of my knowledge. I understand that reimbursement is subject to the institution's tuition reimbursement policy, available funding, and compliance with eligibility criteria below.

Eligibility and conditions. Reimbursement will be considered only for courses that are job-related or part of an approved degree or certificate program. Reimbursement is contingent upon submission of proof of payment and an official transcript or completion verification demonstrating satisfactory course completion as defined by policy (generally a grade of C or better for undergraduate courses or a grade consistent with program standards for graduate-level courses). Requests must be submitted within 60 days of course completion unless otherwise authorized in writing by the approving official. The institution reserves the right to deny reimbursement if documentation is incomplete or if the course does not meet policy criteria.

Repayment obligation. If employment is terminated voluntarily or for cause within twelve (12) months of reimbursement disbursement, the employee may be required to repay reimbursed amounts in whole or in part as set forth in policy. Reimbursement may be treated as taxable income to the extent required by law; the institution is not responsible for tax consequences to the applicant beyond reporting obligations.

Audit and verification. The institution may verify enrollment, grades, invoices, and receipts. Submission of false or forged documentation is grounds for denial of reimbursement and may result in disciplinary action up to termination.

Acknowledgement: I certify that I have read and understood the conditions above and agree to abide by institutional tuition reimbursement policies and repayment provisions.

Submission Checklist (attach copies)

Official itemized receipt showing payment amount and payee
Official transcript or certificate of completion showing grade or completion status
Course syllabus or description demonstrating course content and credit hours
Prior written approval (if required) or supervisor confirmation

Administrative Use Only

Approval Decision: Approved Denied

Amount Approved: $    Budget Account:

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