CITY OF TEMPLE CITY

EDUCATION REIMBURSEMENT FORM

EMPLOYEE NAME / FISCAL YEAR
JOB CLASSIFICATION / DEPARTMENT

Education Reimbursement Benefit Conditions

TheCitywillprovidereimbursementtotheemployeeaccordingtothemaximumamountandqualifyingfactors describedinEducation Reimbursement Program Policy.TheEducation ReimbursementProgramwilloperateonafiscalyearbasis(July1throughJune 30). Theemployeewillberesponsibleforanyincometaxesdueonthiseducation reimbursementbenefit.

INSTRUCTIONS

1.Submitthisform toyourDepartmentDirectorbeforethecourse(s)beginsinordertoqualifyfortuition reimbursement.

2.Aftertheapprovalsaregiven,thisformwillbereturnedtoyoutoholduntilthecompletionofthecourse(s).

NOTE: Education Reimbursement request must be pre-approved by the Department Director and the Administrative Services Director, before the course(s) begin, to qualify for reimbursement, no exceptions.

COURSE TITLE / COURSE NO. / UNDERGRAD OR GRAD PROGRAM / EMPHASIS OF DEGREE / COURSE UNIT

My reimbursement tuition request includes:

Tuition: $ ______/ Fees: $ ______
Books: $ ______/ Parking: $ ______
Other: $ ______
Total Education Reimbursement Request: ______

Description of course content as outlined by the school catalog: Please attach a printed course description.

______

______

Relationship of coursework to your position: How does this course relate to the requirements of your position?

______

______

I have read and understand the terms of the Education Reimbursement Program Policy that apply to this education reimbursement employee benefit.

Employee Signature: ______Date: ______

PRE-APPOVALS

Reimbursement Account Number (*Required): ______
DEPARTMENT DIRECTOR: ______Approved Denied Date: ______

ADMINISTRATIVE SERVICES DIRECTOR: ______Approved Denied Date:______

COMMENTS: ______

Updated July 2, 2012

CITY OF TEMPLE CITY

EDUCATION REIMBURSEMENT VERIFICATION REQUEST

______

EMPLOYEE NAME

I certify that I have completed the coursework described and that all documents regarding course completion and reimbursements are true and correct.

Attached are:

  1. Final grade report or a completion report for classes that are not graded.

I understand and accept the conditions of the advanced tuition agreement that are described in the Education Reimbursement Program Policy for my job classification regarding the requirements for continued employment.

______

EMPLOYEE SIGNATUREDATE

VERIFICATION AUTHORIZATION

ADMINISTRATIVE SERVICES DIRECTOR: ______DATE: ______

COMMENTS: ______

Updated July 2, 2012

CITY OF TEMPLE CITY

EDUCATION REIMBURSEMENT REQUEST

______

EMPLOYEE NAME

I certify that I have completed the coursework described and that all documents regarding course completion and reimbursements are true and correct.

Attached are:

  1. Final grade report or a completion report for classes that are not graded.
  2. Tuition and book receipts issued by the college and institution conducting the course.

I understand and accept the conditions of this reimbursement that are described in the Education Reimbursement Program Policy for my job classification regarding the requirements for continued employment.

My reimbursement request includes:

Tuition / $ ______
Fees / $ ______
Books / $ ______
Parking / $ ______
Other: ______/ $ ______
TOTAL / $ ______

______

EMPLOYEE SIGNATUREDATE

VERIFICATION AUTHORIZATION

ADMINISTRATIVE SERVICES DIRECTOR: ______DATE: ______

COMMENTS: ______

Updated July 2, 2012