Form # 2–Request for Reimbursement

TUITION REIMBURSEMENT PROGRAM

Instructions for Employee:

Complete both pages of this form.

Carefully read and sign and Repayment Agreement portion on the next page. This obligates you to repay money to the Company if you voluntarily quit.

Attach a copy of your courses, grades, tuition and covered fee receipts for the covered courses – OR – ask your College/University to complete the section of this form marked “TO BE COMPLETED BY COLLEGE OFFICIAL”.

Send original form and any attachments to your local Human Resources manager.

LAST NAME / FIRST NAME / MIDDLE INITIAL / SOC SEC NO / PAYROLL/CLOCK NO
STREET ADDRESS / CITY / STATE / ZIP CODE / HOME PHONE
JOB TITLE / DEPARTMENT / HIRE DATE / MAIL CODE / WORK PHONE
NAME OF COLLEGE / ADDRESS OF COLLEGE

COURSE DATA

CATALOG NUMBER / COURSE TITLE / CREDIT HOURS / TUITION / FEES / TOTAL
$ / $ / $
$ / $ / $
$ / $ / $

The course work listed above is a requirement that I am presently pursuing for:

DEGREE: / MAJOR:
SEMESTER
QUARTER / STARTING DATE / ENDING DATE
[check one] / [Fall, Winter, Spring, Etc.] / [month] / [day] / [year] / [month] / [day] / [year]

TR Form #2 (R1)Page 1 of 2

I understand that I must fulfill the requirements of the tuition reimbursement program to receive reimbursement. I understand that completing a program of study does not guarantee that I will be promoted or transferred to another job. I also understand that the Company reserves the right at its sole discretion, to make any changes or modifications to the tuition reimbursement program including the right to terminate the tuition reimbursement program or any portion thereof, at any time.

I understand, agree to and have signed the Repayment Agreement on page 2 of this form. I also agree to inform the Company of any changes that may affect payment under the tuition reimbursement program. I hereby authorize the Company to obtain or otherwise have access to grades and other information pertaining to the courses listed on this application.

I understand that the falsification or withholding of relevant information in conjunction with application to or participation in the tuition reimbursement program is a serious matter that may result in the denial of reimbursement, the recoupment of payments, and/or other employment-related consequences.

Employee Signature / Date

TO BE COMPLETED BY COLLEGE OFFICIAL:

Under the conditions of our tuition reimbursement program, the above Company employee has applied for reimbursement on the courses listed above. Please complete the information for each course the employee was enrolled in and return it to the employee.

CATALOG NUMBER / COURSE TITLE / GRADE / CREDIT HOURS / TUITION / FEES / TOTAL
$ / $ / $
$ / $ / $
$ / $ / $
Degree sought by employee: / In [degree program]:
College Official / Title / Date

TR Form #2 (R1)Page 1 of 2

Repayment Agreement

The approval of your request to participate in the Company’s tuition reimbursement program for the course(s) described on page 1 of this form is contingent on your compliance with the terms of the Company’s Tuition Reimbursement Policy.

If you remain employed with the Company for at least two years after you have completed the approved course(s), you will not be obligated to repay to the Company any portion of the tuition and covered fees advance that you receive. However, if you voluntarily leave the Company or are terminated (other than due to a workforce reduction or position elimination) within two years of the completion of the course(s), you agree to repay to the Company upon termination the following amount:

a.100% of the amount advanced if employment terminates less than one year after completion of the course(s); or

b.50% of the amount advanced if employment terminates at least one year, but less than two years, after completion of the course(s).

The Company is hereby authorized to withhold the appropriate amount as described above advanced from your final paycheck and any other amounts due to you upon termination. If the amount advanced is not repaid in full when due, the Company may recover from you, in addition to the amount advanced, the costs and legal expenses of collection, and report the debt to credit reporting organizations.

By your signature below, you acknowledge that you have voluntarily decided to take the course(s) and to obtain payment of the cost of tuition and covered fees from the Company pursuant to its Tuition Reimbursement Policy.

AGREED:

Employee Signature / Date

Other Information [PLEASE PRINT]

Number of credit hours earned: / Number of credit hours for degree:
Expected graduate date: / G.P.A. [overall] / Major G.P.A.

Are you receiving or eligible to receive education assistance from any other source, for example veterans benefits; Career Development Program, scholarships?

Yes / Amount: $ / No

APPROVAL

I hereby approve this request for reimbursement.

I hereby disapprove this request for reimbursement, the following reason:

Human Resources / Date

TR Form #2 (R1)Page 1 of 2