Educational Assistance Plan Reimbursement Form

Team Member Name: Daytime Phone #: ID#: SSN:

Address:

Center/Dept #:

Date of Hire:

Part Time Employee Full Time Employee

Graduate Degree __________ Undergraduate Degree __________ Dates of Courses mm/dd/yyyy

From: To: From: To: From: To: From: To:

Today's Date: Field of Study:

Course Title

Educational Institution

Tuition

Course Fees

Cost of Textbooks

Other Related Materials

Total

Grand Total

Approval Name (please print):

Approval Signature:
I hereby verify that the team member is currently employed and has not been on any disciplinary action within the last six months from the date of application.

Approver Work Telephone Number: Other financial assistance $ Source(s)

Center/Dept #:

Today's Date:

Reimbursement is limited to $750 per term for undergraduate courses and $1,250 per term for graduate level courses. Annual maximum of $1,500 for undergraduate level courses and $2,500 for graduate level courses. Copy of grade report and original receipts for all

expenses must be submitted with this form. Forward completed form to: HEALTHCOMP, INC. P.O. Box 45018, Fresno, CA 93718-5018 Questions: 800.442.7247, Option #3 Fax: (559) 499-2045 Please read the Summary Plan Description at fedexoffice.ehr.com for additional program details.

Rev. 100709