COMMUNITY RESOURCES FOR JUSTICE
Tuition Reimbursement Form
Eligibility: Full-Time Active Employees
Instructions:
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Read the Tuition Reimbursement Program Policy: CRJ will reimburse an eligible employee up to $1,500 per fiscal
year for out-of-pocket payments for courses in undergraduate, graduate, and professional certificate programs.
Be prepared to submit to HR Benefits: (F) 617-423-2268; (E) apreston@crj.org, for review and approval the
following documentation:
o The Tuition Reimbursement Form.
o Written acceptance into the course or program from the accredited college or university.
o Bills and receipts that reflect the out-of-pocket payments, which may include payments through student loan
programs, of tuition, text books, registration fees, course fees, and lab fees.
o Copy of the final grade report, which reflects a passing grade of at least “C” or better.
For questions or for additional information call Benefits @ 617-423-2020, x2108
Note: Not following the above instructions may delay any approval and reimbursement.
Date: ____/____/____
Employee Name: _________________________________
First and Last Name (Print)
Telephone No.: _________________
Email: ______________________________
Position Title: __________________________
Department/Program: _________________
Location: _____________________________
Name of Accredited Higher Education Institution: _____________________________________________
Street Address: ___________________________ City: ________________________________________
State: ________________
Zip Code: __________
Educational Program (Check One):
2 year: ____
4 year: ____
Semester (Check One): Fall: ____
Course(s) Elected:
Graduate: ____
Professional Certificate: ____
Winter: ____
Spring: ____
Summer: ____
___________________; ___________________; __________________________
I certify that the information submitted on this form is true to the best of my knowledge. I understand that if any of the
information is determined to be false, CRJ reserves the right to seek reimbursement of any monies paid under the plan,
and I will lose my right to any further reimbursements under the plan.
Employee Signature: ______________________________________ Date: ___/____/____
Revised: 12/30/2013