EMPLOYEE TUITION BENEFIT FORM
FOR UMC EMPLOYEES TAKING CLASSES AT UMC ONLY
This form is only for use by full time UMC employees who have completed their 90 day
probation period by the first day of class, who have registered for courses booked through
UMC. Departmental approval is required. Employees taking courses at Ole Miss should not
use this form. The Human Resources forms index has the form for courses taught at Ole Miss.
NOTES:
The Employee Tuition Benefit (ETB) only pays for 6 hours per semester. Anything above that
must be paid by the employee by the due date. Amounts due from the employee are subject
to late fees if not paid on time. ETBs will not be credited to the tuition accounts until AFTER
the add/drop period is over. You may receive one or two tuition bills in the meantime. If
you need help figuring out how much of the bill you are personally responsible for please
consult the fee tables at http://academics.umc.edu/student_accounting/cost.html or contact
Student Accounting at acct-student-accounting@umc.edu. To find the last add/drop date for
the term, please consult the Important Dates listing at https://myu.umc.edu/irj/portal
INSTRUCTIONS:
Book your courses for the term.
Complete all sections of the ETB form. If you do not know your student number, please
provide the last 4 digits of your Social Security Number.
Provide your employee number and your full name. If you use a different version of
your name on your student records, provide both versions please.
Have your department head sign the ETB form and provide an Accounting Unit. The
Accounting Unit to use is the one your fringe benefits are paid from. The tuition will be
charged to that accounting unit.
Only turn in one ETB form at a time. You must complete a new form for each academic
term. If you are booked for more than one future academic term wait until the future
term is about to start before turning in an ETB for that term.
Print the ETB form and complete all sections. Sign and initial the ETB form where
indicated. Turn the form in to Student Accounting. It will be time stamped and you will
be given a copy for your records. Retain that copy in case of disputes.
ETB FORM SUBMISSION DEADLINES:
SUMMER SEMESTER………….JUNE 15
FALL SEMESTER………….AUGUST 20
SPRING SEMESTER……..JANUARY 20
SUMMER AND FALL INTERSESSIONS: ONCE YOU BOOK THE COURSE, OR BY START OF CLASS
THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
EMPLOYEE TUITION BENEFIT FORM
This form is good for one academic term and will pay for up to 6 credit hours. Employees are responsible for
paying for excess hours not covered by the Employee Tuition Benefit (ETB), late fees and service charges
incurred if the ETB form is not turned or the portion due from the employee is not paid on time. You must be
a full time employee, have completed the 90 day probation period by the first day of class, and have
departmental approval.
Please read the following items and initial on the line:
______
The ETB will not be credited to my tuition account until after the last add/drop
date for the term.
______
I understand that I will receive bills from Student Accounting until my account is
paid in full, even if I have paid my part of the balance.
______
I understand that I must retain the time stamped copy of my ETB which is my
proof that I have turned it in to Student Accounting.
______
I understand that my account is subject to late fees if not paid on time and that
Student Accounting can tell me how much I need to pay while waiting for my ETB to be
posted, and that I can sign up for payroll deduction to pay my part.
By signing below, you take responsibility for reading and understanding the instructions and
notes regarding the processing of the Employee Tuition Benefit form, due dates for
submission, and the employee’s responsibilities as regards the payment of their account.
Employee Name______________________________________________________
Student ID # or last 4 of SSN__________________
Employee #______________
Telephone number (work)__________________(home or cell)________________
Email address________________________
TERM (CIRCLE ONE):
SUMMER
SUMMER INTERSESSION
FALL
FALL INTERSESSION
SPRING
Department Head Signature____________________________________________
Dept. Head Name (please print)_________________________________________
Accounting Unit_____________ Account __60230__
Activity (if paid off a grant)__________________________
OFFICE USE ONLY:
HR_________
AMT___________