HR: Tuition Assistance Application

Tuition Assistance Application
Hidden Form Name
NOTE:
Employee Type *

Employee Type Full-Time Classified Part-Time Classified Hourly Instructional/Teaching Faculty AP Faculty Medical Admin Faculty Medical T&R Faculty
SECTION 1
Employee UIN *
Must be 8 characters. Currently Entered: 0 characters.
Employee Name *
Work Email *
Cell Phone Cell Phone - ### - ### ####
Work Phone Work Phone * - ### - ### ####
Did you have service at EVMS prior to starting at ODU? *

Did you have service at EVMS prior to starting at ODU? Yes No
If yes, when did your date of continued service start at EVMS? If yes, when did your date of continued service start at EVMS? / MM / DD YYYY
This application is for the following semester (Summer term is not available for dependents): *
SECTION 2
I am requesting tuition assistance for my -

I am requesting tuition assistance for my - Spouse/Dependent (as defined by current IRS regulations) N/A skip to Section 3

(A separate application must be submitted for each family member)
Spouse/Dependent's UIN
Must be 8 characters. Currently Entered: 0 characters.
Spouse/Dependent's Name
Spouse/Dependent's Email Address
Spouse/Dependent's Cell Number Spouse/Dependent's Cell Number - ### - ### ####
SECTION 3
Course Information : Please complete all information for each course for which tuition assistance is being requested.
Tuition Assistance Program:

NOTE: Payment of funds for tuition only, per-credit-hour, not to exceed the Old Dominion University in-state tuition rate. Fees and other related charges will not be covered and are the responsibility of the employee. All tuition assistance provided is contingent upon availability of funding.

Classified Employees: 6 credit hours Fall, Spring and Summer sessions
Instructional and AP Faculty: 6 credit hours Fall, Spring and Summer sessions
Medical AP and T&R Faculty: 6 credit hours Fall, Spring and Summer sessions
Part-time classified and Wage employees: - 3 credit hours Fall, Spring and Summer sessions
Dependents/Spouse of eligible members: - 6 credit hours Fall and Spring sessions only
Military/ROTC: 6 credit hours Fall, Spring and Summer sessions
Course 1
Course 1 Title *

(i.e College Algebra)
Course 1 Number *

(i.e MATH 102M)
Course 1 CRN *
Must be 5 digits. Currently Entered: 0 digits.
Select if Course 1 is a graduate or undergraduate course
Credit Hours For Course 1 *
Course 2
Course 2 Title
Course 2 Number
Course 2 CRN
Select if Course 2 is a graduate or undergraduate course
Credit Hours For Course 2
Course 3
Course 3 Title
Course 3 Number
Course 3 CRN
Select if Course 3 is a graduate or undergraduate course
Credit Hours For Course 3
Course 4
Course 4 Title
Course 4 Number
Course 4 CRN
Select if Course 4 is a graduate or undergraduate course
Credit Hours For Course 4
Select yes if you still have courses to include
Course 5
Course 5 Name
Course 5 Number (CRN)
Credit Hours For Course 5
Select if Course 5 is a graduate or undergraduate course
Course 6
Course 6 Name
Course 6 Number (CRN)
Select if Course 6 is a graduate or undergraduate course
Credit Hours For Course 6
*

The requestee is confirming that the employee received approval from their supervisor to take this course(s). (If release time is required then it must be approved by supervisor) N/A - this application is for a spouse/dependent or does not require release time.
Tuition Assistance Program: Terms of Agreement

1. If an employer pays more than $5,250 in tuition assistance benefits for an employee during the year, the employee must
pay tax on the amount over $5,250. This amount will be included in your wages on Form W-2, box1.
2. Payment of the course becomes the responsibility of the employee if the employee;
a. Receives a grade of less than a B- for graduate courses, a C- for undergraduate courses or Incomplete.
b. Drops or withdraws (W/WF) from an approved course after the add/drop deadline.
c. The employee terminates employment during the semester in which tuition assistance was last approved.
3. Tuition assistance may not be approved if:
a. The employee dropped, withdrew, receives a grade of less than a B- for graduate courses, C- for undergraduate
courses or receives a grade of I-Incomplete (that is not cleared by the deadline established by the Registrar) for two or more semesters.
4. If requirements of this program are not met, the tuition assistance will be withdrawn and the student will receive a bill from the Office of Finance. The student will be responsible for payment of the bill immediately. Late fees and, if applicable, collection fees may be assessed by the Office of Finance and becomes the responsibility of the student.
5. If applying for federal or state financial aid, the employee must report the receipt of tuition assistance to the Office of
Student Financial Aid. Tuition assistance may affect the amount of federal or state financial aid received.
6. The request for tuition assistance is contingent upon the availability of funds and will be approved based on the seniority of employees applying for tuition assistance. If funds are not available at the time the request is submitted, the indebtedness for the course remains the responsibility of the student.
7. Payment for any course will not exceed the in-state tuition rate for Old Dominion University.
8. Failure to comply with the tuition assistance program policy may influence future decisions concerning tuition
assistance.
9. Changes to the original application (drop/add/withdrawal) must be reported immediately to Human Resources at tuitionassistance@odu.edu.
10. Changes to the original application that result in an increase in the amount of tuition assistance requested may only be
approved if funds are available.
Please check the box to confirm your acknowledgement *

Please check the box to confirm your acknowledgement By Signing this form I agree to allow ODU Registrar's office to release my grades to the Department of Human Resources for the purpose of verifying that courses being paid for by this benefit have been successfully completed. If requirements of this program are not met, the tuition assistance will be withdrawn, and the student will receive a bill from the Office of Finance. The student will be responsible for the payment of the bill immediately. Late fees and, if implicable, collection fees may be assessed by the Office of Finance and are the responsibility of the student.
If you have any questions regarding tuition assistance please email tuitionassistance@odu.edu.
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY
Email Address To Send Confirmation *

HR: Tuition Assistance Application

Tuition Assistance Program:

Course 1

Course 2

Course 3

Course 4

Course 5

Course 6

Tuition Assistance Program: Terms of Agreement