Tuition Reimbursement Form (Incomplete forms will not be processed) General Instructions: Email completed reimbursement form /receipts to HR4U@rhanet.org Email Subject Line: Tuition Reimbursement, Employee Name, and Employer ID.
Employee Name: ___________________Employee ID#: __________Phone Number: _______________ Course of Study ___________________________ Begin Date : ___________ End Date: _____________ *Course, begin, dates, Receipts and grades should reflect the approved education interest form
Indicate Final: Grade: Pass (______) Fail (______) * Attach supporting documentation
Enter total tuition charges for semester/quarter: $________________________ Enter total amount you paid out of pocket & Requesting Reimbursement: $ ________________
_____________________________________________________________________________
Employee Signature: ____________________________________________ Date: _________________ Director Signature:
______________________________________ ______Date: _________________
*Director signature attest grades and receipts are approved for processing
ADMINISTRATIVE USE ONLY (Submitted for processing)
Ticket #: ____________Date Submitted: _____________ Submitted by: _____________________________________ Approved $ ______________________
(Maximum reimbursement 50% not to exceed $2,000 annually)
02/09/2025