2/2015
LIFETIME ASSISTANCE, INC.
425 PAUL ROAD
ROCHESTER, NEW YORK 14624
An employee will be considered eligible to apply for tuition reimbursement if they have completed one year of service in a benefits eligible position and are regularly scheduled for 20 hours or more per week, providing that employee currently has no outstanding written reprimands in their personnel file when applying for tuition reimbursement,. All tuition assistance courses must be applied for prior to the posted deadlines. Requests should be submitted on the Tuition Reimbursement Request Form to the Human Resource Department via your immediate supervisor and appropriate Program Director. The agency will reimburse 1/2 the cost (tuition only) for
2 standard credit courses per semester, for a maximum of six courses per calendar year based upon the tuition for the least expensive institution offering such courses within the Rochester Area College Community. Employees must satisfactorily complete the course(s) with a passing grade to be eligible for reimbursement. Additionally, prior to signing off for payment of tuition reimbursement an employee, the Human Resource Department must verify that the employee has no current written reprimands in their personnel file. If you are required to continue your education in order to maintain your current position within the agency, you will be reimbursed 100% of your tuition, fees, books and all associated costs.
Coursework must be career-related as defined by: (determined by Personnel Committee) a) directly relating to the employee’s current job assignment, duties and/or responsibilities; or b) increase the employee’s opportunity for advancement within the employee’s title series; or c) increase the employee’s opportunity for advancement to positions for which the employee may compete on a promotional basis; or d) be a specific course or subject or requirement of a degree program which is itself, career-related; e) enable the employee to acquire knowledge or skills for which there exists a need in agency service; f) directly increase managerial effectiveness through acquisition of needed skills or g) provide a non-degreed employee a college degree which is necessary for expanded career opportunities within the agency service.
A copy of a validated bursar’s receipt indicating the amount paid for the course and a copy of your grades indicating successful completion of the course must be presented at the end of the term for reimbursement purposes.
SEMESTER DEADLINE FOR
APPROVAL
DEADLINE FOR
REIMBURSEMENT
Summer
Fall
July 1
October 1
October 1
February 1
Spring February 1 July 1
Adjustments will be made for courses taken on the quarter system . Reimbursements will not be paid if you have submitted your resignation or are no longer employed.

2/2015
If you have completed one year of service in a benefits eligible position and you are regularly scheduled for 20 hours or more per week and have no current written reprimands in your file when applying for tuition reimbursement or when the reimbursement is paid you are eligible to participate in the tuition assistance program. Lifetime Assistance, Inc. will reimburse one half the cost of tuition ONLY (no books, fees or other costs) for two regular credit courses each semester for a total of six per calendar year based upon the tuition for the least expensive institution offering similar courses within the
Rochester Area College Community. You must satisfactorily complete the course to be eligible for tuition reimbursement.
Tuition reimbursement is paid through payroll and is taxable if the amount exceeds $5,250 in any year.
NAME:____________________________ SEMESTER/QTR:____________________
WORK LOCATION:____________________ POSITION:_______________________
COLLEGE:________________ DEGREE PROGRAM:____________ U ____ G ____
HAVE YOU RECEIVED TUITION ASSISTANCE FROM LIFETIME ASSISTANCE THIS CALENDAR YEAR?
IF SO, FOR WHAT SEMESTER/QUARTER (please circle): SUMMER FALL WINTER SPRING
*********************************
COURSE # ___________________ NAME: _________________________________________
DAYS AND HOURS: ___________________________________________________________
# CREDITS: ___________ TUITION PER CREDIT $: _______ TOTAL_________________
COURSE # _________________________ NAME: ___________________________________
DAYS AND HOURS: ___________________________________________________________
# CREDITS: ___________ TUITION PER CREDIT $: ______ TOTAL__________________
JUSTIFICATION (How coursework relates to job as defined by the Tuition Assistance Policy)
______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I understand that it is my responsibility to provide a validated bursar’s receipt and a copy of my grades prior to the announced deadline in order to receive reimbursement. I further agree to inform the Human Resource Department if I drop out of this course.
EMPLOYEE SIGNATURE: ___________________________________________ DATE: __________
SUBMIT TO IMMEDIATE SUPERVISOR

REQUEST APPROVED

REQUEST DISAPPROVED: _________________
SUPERVISOR’S SIGNATURE: ________________________________________ DATE: _________
SUBMIT TO PROGRAM DIRECTOR

REQUEST APPROVED

REQUEST DISAPPROVED: _________________
SUPERVISOR’S SIGNATURE: ________________________________________ DATE: _________
SUBMIT TO HUMAN RESOURCE DEPARTMENT

REQUEST APPROVED

REQUEST DENIED AMOUNT APPROVED ____________
HR BENEFITS SPECIALIST: ________________________________________ DATE: __________