Tuition Reimbursement Tax Withholding Information

Tuition Reimbursement Tax Withholding Information
Please provide your details and tax withholding preferences for tuition reimbursement processing.
Full Name
First NameLast Name
Employee ID (Last 4 Digits Only)
Department
Work Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Reimbursement Amount Requested (USD)
Course or Program Name
Course Completion Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Tax Withholding Method
Other (please specify)
Upload Proof of Course Completion (e.g., transcript, certificate)
Cancelof
Additional Comments or Special Instructions
Should be Empty: