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Educational Assistance Reimbursement Form Job Title: Department: Department Head/Director Name: Total tuition amount or fee requested (Sum of all Calculated Reimbursements from above) I understand that, if my full -time employment is terminated with the City for any reason within two years of receipt of tuition reimbursement , I agree to reimburse the City, in full, for tuition assistance/reimbursement paid by the City. Employee Signature Date Employees that have been approved for tuition reimbursement are required to complete the Tuition Reimbursement Payment Form and provide copies of transcripts outlining final grades within 30 days from the end date of the course. Please complete the information below and attach supplemental documentation. Employee Name: Tuition Reimbursement Payment Terms Final grade must be equivalent to an “Pass” or completion certificate. • For a grade of – 100% of reimbursable costs • For a grade of – 80% of reimbursable costs • For a grade of – 60% of reimbursable costs • If the approved course is pass/fail, 100% of reimbursable costs will be paid for passing a “pass/fail” course. Course Title Tuition Cost Final Grade Eligible Reimbursement Example: Math 101 $2,000 B $1,600 ($2,000 x 80%) Dept Head Signature Date Note: The final reimbursement will be determined by a review of eligible expenses, final grades, and annual policy maximums. See policy for details. SIGN SIGN