Www.uwsp.edu



REQUEST FOR TUITION ASSISTANCE

University of Wisconsin – Stevens Point

PRIOR TO REGISTERING FOR A COURSE, this form must be completed and approved by the Department Chairperson or Supervisor, Dean or Executive Director, Human Resources, and Vice Chancellor, to be eligible for reimbursement of tuition. (Prior approval needed according to GAPP #25). Employees will be reimbursed upon successful completion of the course, by submitting the proper documentation. Reimbursements will be completed through direct deposit. Unclassified and classified employees are eligible for reimbursement if they have an ongoing appointment of 1.0 or have a full-time appointment during the academic year. Limited Term Employees (LTE), employees-in-training, and student employees are not eligible. See the Tuition Reimbursement Program guidelines for details, including information on how changes in employment status may affect tuition reimbursement.

Page 1 to be completed by Employee

|Employee Name: |      | |UWSP ID No.: |      |

|Home Mailing Address: |      |City/State/Zip: |      |

|Classification/Title: |      | |Employing Department: |      |

|Type of Appointment: | Unclassified; Classified | |

| | |

|Institution Attending*: |      | |Type of Degree (if applicable): |

|Address/City/State/Zip |      | | Doctoral** |      | |

|Phone No.: |      | | Graduate |      | |

| | | | Undergraduate |      | |

|Course No.: |      | | Other |      | |

|Course Title: |      | |**Documentation of acceptance & enrollment in a doctoral|

| | | |program is required for reimbursement at this level. |

|No. of Credits: |      | |Fee/Instruction Cost:*** |$      | | |

| | | | |

|Semester Attending | Winterim 20      Spring 20      |If your supervisor is requiring you to take this course,|

| | |contact the HR Manager in Personnel Services (extension |

| | |3933). Otherwise, it will be processed under the |

| | |guidelines for “requested by employee.” |

| | Summer 20      Fall 20      | |

|Dates of Course: |Start Date:      End Date:      | |

| | | |

|***At the time of submitting this form, attach a printout of the per credit cost for tuition. |

| Upon completion of course, submit a copy of the course grade report or certificate of completion (if no grade is given), |

|and itemized paid receipt for course fees, to Accounts Receivables Office in the Student Services Center. |

Are you receiving other financial assistance to pay for tuition? No Yes, type: Grants; Scholarships; Loans

Identify source and dollar amount of all financial assistance:

|      |

| |

Describe how this course will assist you in career progression or why it is related to your current job. Indicate if working toward an undergraduate, graduate, doctoral degree, or other certification. (If this is your first request for tuition reimbursement, for a course that is part of a degree program, please complete the Supplemental form in lieu of completing this question.)

|      |

If coursework must be taken during your normal working hours, briefly explain arrangements to make up for time not worked:

|      |

*Reason for attending non-UW institution (if applicable):

|      |

|NOTICE: Due to the frequent changes in tax laws regarding tuition reimbursements, the most recent IRS regulations should be consulted regarding potential tax |

|liability. (For example, 2012 IRS rules exempt educational assistance payments from payroll tax up to $5,250 per calendar year; amounts paid out in one calendar |

|year that exceed this amount are subject to tax as wages.) |

I acknowledge that I have read the tuition assistance guidelines, which includes information on how tuition reimbursement is affected for employee reassignment, resignation, and termination. I will submit a new form for any course changes.

Employee’s Signature:_________________________________________________________ Date:_______________________________

|Employee Name: |      | |Course No.: |      |

Department Chairperson’s or Supervisor’s Approval

Explain how this course relates to employee’s career progression or assists in providing improved job performance. (If this is the employee’s first request for tuition reimbursement, for a course that is part of a degree program, the Supplemental form must be completed in lieu of completing this question.)

| |

| |

| |

|Signature: | | |Date: | |

| | | | | |

|Print Name: | | | | |

| |

Dean/Executive Director’s Approval

If this employee is paid in whole or in part from funds other than general program revenue (GPR), e.g. Program Revenue (PR) or Federal Program Revenue (PRF), indicate the account to be charged for reimbursement.

|Account to be Charged: | |

|Signature: | | |Date: | |

| | | | | |

|Print Name: | | | | |

| |

Human Resources Office Approval

Employee is ( Classified ( Unclassified FTE: _____________ Is the institute accredited? ( Yes ( No

The course is: ( Career-related ( Job-related, give details for exception:____________________________________________________

( Eligible for reimbursement:

Eligible for reimbursement of 100% of instructional costs and waiver/reimbursement of segregated fees up to the maximum of

the following credit tuition fee, charged at UWSP, to in-state students:

( Clinical Doctoral in Audiology ( Graduate ( Undergraduate

( Course is required by supervisor: All instructional costs should be paid by the employee’s unit at the time of enrollment.

Segregated fees should be paid by the unit or waived when possible.

|( Decline: The request for tuition reimbursement is declined because: | |

|Signature: | | |Date: | |

| | | | | |

|Print Name: | | | | |

| |

Assistant or Vice Chancellor’s Approval

|Signature: | | |Date: | |

| | | | | |

|Print Name: | | | | |

| |

For Accounting Use Only

| | | | | | |

|Date Received: | |Accounting String: | |Amount: |$ |

|( Job-related |( Career-related |Comments: | | |

| | | |

|Authorized by Controller: | | |

|Signature: | | |Date: | | |

|Print Name: | | | | |

| |

-----------------------

[pic]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download