Tuition Reimbursement Request

Agreement
In accordance with IRS regulations, tuition assistance provided in excess of $5,250 in a calendar year is considered taxable compensation and is subject to withholding taxes. Accordingly, once this limit is reached, the excess will be included as earned compensation on your paystub with the appropriate taxes withheld ratably over the remaining course period(s).
Please verify*

I have read and agree with the information and terms on this form.

1) Supervisor/Manager Approval

Please complete the Name and Signature fields in this section and Submit on the next page. This form will automatically be routed to HR for the next round of approval.
Supervisor/Manager Name

First NameLast Name
Supervisor/Manager Signature

Clear
Date

MonthDayYear
Date
2) HR Approval
HR Name

First NameLast Name
The course(s) taken by the above named employee meets one of the following requirements:

Maintains or improves skills required in his/her employmentThe education is required by his/her employer as a condition of continued employmentStatutory Exemption
HR Signature

Clear
Date

MonthDayYear
Date

Courses Taken