Education Reimbursement/Certification Application

The following information must be completed and received in Human Resources no later than 31 day after the course(s) begins.

After the course(s) are complete, an official school statement verifying the grade for each course, a completed Verification of the Educational Expenses form (available in Human Resources). All associates participating in the program must submit copies of any receipts for tuition, lab fees and textbook payments to Human Resources.

Educational assistance amounts will be taxed, as required by law, within the tax year in which the assistance is received. Current tax code allows an associate to exclude up to $5,250 per year in non-graduate level educational assistance. Reimbursement for graduate level courses is treated as taxable income unless the graduate level course is specifically job-related.

Associate Name ______Associate ID #______Date______

Department ______Work Phone ______Home Phone ______

Degree Name/Certification Name ______Semester/Term Dates ______To______

Classes towards a certification are not eligible for Tuition Reimbursement.

Date of Hire ______Full-Time Part-Time Job Title ______

Have you received education reimbursement for SMMC before? YES NO If so when? ______

I wish to apply for education reimbursement for the following courses:

School / Course Name / Credit Hours / Tuition / Lab Fees/Books
What is the degree and job you are seeking?

I authorize Shawnee Mission Medical Center to deduct the prorated amount as outlined in the Administrative Policy #501, from my final paycheck in the event I voluntarily terminate employment from Shawnee Mission Medical Center within twelve months after receiving tuition reimbursement.

Associate Signature ______Date ______

Please present this application to your Administrative Director or Manager to approve and forward it to Human Resources.

Administrative Director or Manager Signature ______Date______

By signing above, you are indicating that your Associate is eligible for reimbursement; Associate has no disciplinary action for the last 6 months and has been employed for a minimum of 6 months.

Human Resources Use Only

Education Assistance Request: Approved Not Approved IF denied, reason:______

Human Resource Signature: ______Date ______