Instructions for Completing the Dependent Tuition Assistance Request Form

Employee Service Center Tuition Assistance U.S. Steel Tower, Floor 56, 600 Grant Street, Pittsburgh, PA 15219 Phone: 1-800-994-2752, option 3 Fax: 412-647-9299 http://infonet.upmc.com/tuition Instructions for Completing the Dependent Tuition Assistance Request Form Read this form and the information on the UPMC Infonet at http://infonet.upmc.com/tuition. Neatly complete ALL requested information. Sign and date the form and submit at the end of the term with required documents to the address or fax above. Please do not submit your information multiple times, send items separately, or include information from more than one term as this only serves to delay the processing of your information. Timely processing depends on your clear, accurate, and complete submission. Eligible Dependents: Eligible dependents include your: legally married spouse or domestic partner dependent child that meets each of the following criteria: is your biological child, stepchild, approved domestic partner s child, legally adopted child, child placed with you for adoption, or child for whom you are an approved foster parent or legal guardian by court order is under age 25 is unmarried and primarily dependent on you for support Proof of dependent status is required (only if not previously supplied). Proof documents include a marriage certificate, UPMC Domestic Partner Affidavit, adoption placement document, foster placement document, or guardianship court order. Birth certificates for children are not to be submitted with your claim; however, UPMC reserves the right to perform periodic audits on benefit eligibility, requesting the appropriate documentation to verify dependent status. Submitting for Reimbursement: The following documents must be submitted within 6 months after the course completion date for reimbursement. Reimbursements can take up to 4 weeks to process and are issued in the next paycheck after processing. Note: Dependent children must maintain 12 credits throughout the term (unless approved by UPMC for a qualified medical exception). Use this checklist to guide you in submitting all the required items for reimbursement: Information from the school must be pre-printed by the school and include the student s name, semester, and school. Completed and signed Dependent Tuition Assistance Request Form - Print a new form from the Infonet each term to make sure you are using the most current version. - A separate request form is required for each term. Invoice/itemized bill - Must specify exact amount of tuition, fees, and other charges as well as show the term, student, and school. Official proof of payment showing method of payment - You must account for how the total bill for this term was paid. A receipt from the school is only acceptable if it clearly itemizes payments. If it does not, you will have to supply a copy of your cancelled check, credit card statement, verification of grant/scholarship award, or other documentation that details each payment s source. Proof of successful completion - grade report - Must obtain an A, B, C, P, or S grade for each course. - Children attending summer semester courses must also provide a grade report from the spring semester of that year as proof they completed the spring term as a full-time college student. Proof of qualifying dependent status (only if not previously supplied) - Must meet the definition of an eligible dependent as shown above in Eligible Dependents. A marriage certificate, UPMC Domestic Partner Affidavit, adoption placement document, foster placement document, or guardianship court order must be on file with UPMC Employee Service Center. A Note About Taxes: Assistance received by staff members for dependents is taxable. Federal, state, and local taxes will be deducted from your reimbursement at the time of payment. Repayment of Tuition Assistance: Staff members must repay any tuition benefits received if termination or change to an ineligible status occurs within 12 months from the course completion date. Repayment is taken from your final UPMC pay (including vested paid time off payout) and any remaining balance is to be paid directly to UPMC within 30 days of termination. Page 1 of 2, Rev 4/1/14

Employee Service Center Tuition Assistance U.S. Steel Tower, Floor 56, 600 Grant Street, Pittsburgh, PA 15219 Phone: 1-800-994-2752, option 3 Fax: 412-647-9299 http://infonet.upmc.com/tuition Name: DEPENDENT TUITION ASSISTANCE REQUEST FORM See page 1 for completion instructions and documentation requirements. Type or print legibly and complete all information in black or blue ink. Do not use abbreviations or acronyms. Incomplete forms will be returned. Must submit within 6 months after end of term. UPMC Employee ID # (required)*: Staff Member Information Daytime Phone: * If you do not have your UPMC Employee ID Number, you may obtain it in My HUB (select the Human Resources tab and then select View Job Information under My Profile), in Kronos, or from your supervisor. It is not found on your employee badge or health insurance ID card. Relationship (as defined by the dependent definition on page 1): Spouse Student Information Student Name: Student Birth Date: Domestic Partner Adult Does this student hold a bachelor s degree from any institution? Yes No Dependent Child Dependent Domestic Partner Child Institution Information University of Pittsburgh Pitt Student ID Number: Branch: Community College UPMC Proprietary School (UPMC owned school) Vocational/Technical School (approved healthcare majors only) Program/Course Information Do not use abbreviations or acronyms. School: School: School: Documentation Checklist You must submit this form and all of the following items within 6 months after the date classes end. See page 1 for details. Complete all items below Must supply all items listed below for each claim Semester: Fall Spring Summer Invoice/itemized bill Semester Start Date: / / Proof of payment Semester End Date: / / Proof of successful completion (grade report) Degree Program: Associate s Bachelor s Other Proof of qualifying dependent status (only needed if not already Major: supplied - refer to the Eligible Dependent and Proof of Enrollment Status: Full-time student Part-time student Qualifying Dependent Status sections of the attached page 1) Credits: (12 credits minimum for dependent child**) ** Unless your dependent is approved by UPMC for a qualified medical exception. I agree to repay tuition assistance received for coursework completed in the 12 months prior to my employment termination or a change to an ineligible job status. If subject to repayment, I authorize UPMC to deduct the amount owed from my wages by means of payroll deduction without further authorization from me. If I become responsible to repay this tuition assistance by virtue of the end of my employment, I authorize UPMC to withhold any outstanding wages due me at the end of my employment (including vested paid time off payout). A remaining balance is due to UPMC within 30 days of termination. I agree to allow any school or entity that I submit to UPMC for tuition assistance to release to UPMC any information regarding my dependent s enrollment including, but not limited to, registration status, grades, charges, and payments. I am declaring the information I am submitting to be correct and accurate. I understand any intentional false statement is considered an act of fraud. I also understand UPMC periodically performs audits on benefit eligibility. If selected in the audit, I understand I will be required to provide the appropriate documentation to verify dependent status at that time. Staff Member Signature Date Page 2 of 2, Rev 4/1/14

UPMC Subject: Tuition Assistance Program for Dependents of Staff Members Date: 11/1/15 I PROGRAM UPMC provides an educational assistance benefit to dependent children, spouses, and domestic partners of eligible UPMC staff members to pursue further education and training. UPMC is committed to excellence in patient care, research, and education. Through this benefit, UPMC is helping to educate tomorrow s workforce and retain top-flight talent in our region, enriching our staff, their families, and our communities. II ELIGIBILITY A. Eligible Staff Members 1. Job Status (a) Eligible staff members include active UPMC employees classified as regular full-time, flex full-time, job share, and regular part-time. (b) Physicians and staff members covered by a collective bargaining agreement must refer to the terms of their contract for eligibility. Groups not eligible for the UPMC Dependent Tuition Assistance benefit include, but are not limited to, staff at: Carrillo Steam Plant, Ladies Hospital Aid Society, UPP faculty and staff dually employed with UPMC and the University of Pittsburgh, and UPMC Mercy religious staff. (c) Staff members are eligible after one year of service provided the school term begins on or after the eligibility date. Time spent as full-time, flex-full time, job-share, regular part-time, limited part-time, and casual is counted as service time. Temporary status does not count toward the one year eligibility requirement. (d) In the event of position elimination, tuition assistance will be granted for courses that have already begun for the semester during which employment termination occurs and when all other requirements of these guidelines have been met. 2. Mid-Semester Internal Job Transfers Staff members who transfer internally during the school term may be eligible for tuition assistance for that current term. Eligible courses must begin prior to the effective date of transfer. The assistance level is determined by the job status at the start of the term. (a) Eligible mid-semester transfers include transfers: from a business unit covered under these guidelines to a business unit not covered, or from an eligible full-time job status (e.g. regular full-time, flex full-time) to an eligible part-time job status (e.g. regular part-time, job share) or vice versa. (b) Ineligible mid-semester transfers include transfers: from a business unit not covered under these guidelines to a business unit covered, or from an eligible job status (e.g. regular full-time, flex full-time, regular part-time, job share) to an ineligible job status (e.g. limited part-time, casual, temporary, terminated).

B. Eligible Dependents 1. Definitions Use of the term dependent in this document refers to all eligible dependents as defined below except where necessary to specifically refer to one or more types of dependents (such as spouse/domestic partner). The definition of an eligible dependent for tuition purposes is not the same as the definition of an eligible dependent for other UPMC benefits. (a) Spouse The individual to whom the staff member is legally married through a governmental or religious ceremony. A common-law spouse is recognized with an approved common law affidavit on file with UPMC documenting the relationship prior to Sept. 17, 2003. (b) Domestic Partner The individual designated by the staff member as a domestic partner by having a completed and approved Affidavit of Domestic Partnership on file with the UPMC Employee Service Center. (Due to the Ethical and Religious Directives for Catholic Health Care Services, the definition of eligible dependents for UPMC Mercy staff does not include domestic partners.) (c) Dependent Child A dependent biological child, stepchild, legally adopted child, child placed with the staff member for adoption, approved domestic partner s child, authorized foster child, or child for whom the staff member is a legal guardian provided the child is: unmarried; and under age 25; and primarily dependent on the staff member for support. 2. If a staff member s dependent has a change in dependent child, spouse, or domestic partner status during the school term, tuition assistance is based on the dependent s status at the beginning of the term. 3. If UPMC employs both the employee and spouse/domestic partner and both staff members are in a benefit eligible classification, the spouse/domestic partner tuition benefit does not apply. The employees are covered separately under the Tuition Assistance for Staff Members program. The dependent child benefit is eligible under only one staff member (the benefit cannot be doubled). 4. Documentation to verify dependency is required prior to initial claim. Staff must provide a marriage certificate for a spouse or obtain an approved UPMC Domestic Partner Affidavit for a domestic partner adult or child. Children must meet the tuition definition of an eligible dependent child. Documentation is required for any child who is not your biological child, stepchild, or legally adopted child. 2 III IV TOTAL CREDIT LIMIT A. Dependents are eligible for tuition assistance on a maximum of up to 150 credit hours. DEPENDENT STUDENT STATUS A. Spouses/domestic partners can be full-time or part-time students. B. Dependent children must be full-time students throughout the term (generally a minimum of 12 credit hours).

3 1. If an otherwise eligible full-time student becomes disabled due to a physical or medical condition, such that full-time student status can no longer be maintained, coverage may be extended on a limited basis until such time that the student is able to return to full-time student status, provided that no less than nine (9) credits are maintained per semester during this extension and a physician attests that full-time student status can not be maintained due to the physical or medical condition. In no circumstances will this extension of coverage be continued beyond the attainment of age 25. 2. Dependent children who register for and/or begin 12 or more credits at the start of the term and do not complete at least 12 credits during the term are not considered to meet the fulltime student requirement. C. Dependent children can utilize the benefit in the summer semester provided they were enrolled as a full time college student the prior semester (spring). V EDUCATIONAL PROGRAMS A. The benefit is limited to the schools, majors, and maximum degree levels listed below. All courses are subject to review for appropriateness. B. Tuition assistance benefits are limited to students attending the University of Pittsburgh, a community college, or a vocational/technical school. Any other institution is not eligible. Community colleges or vocational/technical schools must be accredited or recognized by the United States Department of Education. C. Dependents attending the University of Pittsburgh, a community college, or a UPMC proprietary school may pursue any major course of study. Dependents attending vocational/technical schools may only pursue a healthcare related major as defined in attached listing found in the appendix. D. Dependent must be pursuing a post secondary/post high school program up to their first bachelor s degree. 1. Eligible programs include: Certificate program, associate s, and bachelor s degree programs correspondence courses, external degree programs, independent study courses, and online, and distance learning College Level Examination Program (CLEP) exams and challenge exams are eligible if credit is received for courses approved according to these guidelines. 2. Ineligible programs include but are not limited to: second bachelor s degree master s or doctorate degree programs college entrance exams initial and periodic renewal of licenses certification review courses and exams continuing education seminars, professional development units, and conferences College in High School (CHS) courses audited courses

4 VI TUITION ASSISTANCE AMOUNT A. Tuition assistance is provided as a percentage of the student s actual out-of-pocket tuition cost up to an academic year maximum. The assistance benefit is based on the student s relationship to the staff member and the staff member s job status (see chart below). The academic year is the 12 month period August 1 through July 31. Generally it starts with the fall semester, continues through the spring semester, and finishes with the summer semester. The start date of a class determines its academic year. Student Full-time and Flex-Full time Staff Percentage of Tuition Academic Year Maximum Regular Part-time and Job-share Staff Percentage of Tuition Academic Year Maximum Spouse/Domestic Partner 50% $2,000 50% $1,000 Dependent Child 50% $6,000 50% $3,000 B. The tuition assistance benefit is limited to the actual out-of-pocket tuition costs only and does not cover any other fees associated with taking classes, such as technology fees, administrative fees, books, room and board, supplies, etc. C. Any non-repayable tuition assistance received from third party sources (e.g. grants, scholarships, and tuition assistance through a spouse s employer) offsets the tuition assistance provided by UPMC. It is the staff member s responsibility to report non-repayable amounts received to the Employee Service Center. Repayable tuition assistance (e.g. loans) is not factored into tuition assistance received. Any eligible tuition discounts are applied before the reimbursement percentage. VII VIII SUCCESSFUL COURSE COMPLETION A. Tuition assistance will be provided only for courses completed with a grade of C or better. B. P or S grade for courses taken on a pass-fail basis is considered the equivalent of a C grade. TUITION REIMBURSEMENT With tuition reimbursement, staff members pay for classes directly to their dependent s school at the beginning of the semester and then request reimbursement of eligible out-of-pocket tuition expenses from UPMC after the completion of the term. Tuition assistance for dependents is offered only on a reimbursement basis. A. Reimbursement is available only for schools and courses eligible under these guidelines. B. Application procedure: 1. At the end of each term, print a new Dependent Tuition Assistance Request Form from the UPMC Infonet at http://infonet.upmc.com/tuition. 2. The completed Tuition Assistance Request Form, an itemized invoice, proof of payment, proof of successful completion (grade report), and proof of dependent status (if not previously provided) must be submitted no later than 6 months after the class end date. Documentation must include the student s pre-printed name, school, and term.

5 3. Once the reimbursement is approved, a notification letter is mailed to the staff member. 4. Reimbursement amounts are included in the staff member s regularly scheduled pay approximately 4-6 weeks after the Employee Service Center receives all the necessary documentation. Appropriate taxes are deducted from the reimbursement (currently includes federal, state and local). 5. Reimbursement will be provided for courses completed successfully. In cases where a course is not completed successfully (e.g. below a C grade, incomplete, withdrawal), the eligible benefit amount is calculated based on the percentage of credits completed successfully in relation to the total credits taken in that term. IX PRE-ELIGIBILITY VERIFICATION A. Staff members who want to obtain general verification of eligibility prior to the start of a term may print a Tuition Assistance Eligibility Verification Form from the UPMC Infonet at http://infonet.upmc.com/tuition and submit it to the UPMC Employee Service Center. The form will be reviewed and a response concerning the eligibility will be mailed to the staff member within four weeks. B. Verification is based on the staff member s self-reported information and is not a guarantee of payment. A review of the actual documentation and specific information of the actual reimbursement submission will determine exact eligible payment amounts as additional criteria are reviewed at that time including: dependent status, successful completion, available maximum, employee s job status, timely submission, proof of payment, and non-repayable third party payments. C. Completion of a Tuition Assistance Eligibility Verification Form is not required to qualify for the tuition assistance benefit. X EMPLOYMENT COMMITMENT Staff members receiving dependent tuition assistance are expected to remain in a tuition eligible employment status for 12 months following the completion of the course in which tuition assistance was provided. Staff who do not remain in an eligible status are required to repay any disqualified tuition assistance received. A. An ineligible employment status occurs when: employment terminates (with the exception of position elimination, reduction in force, divestiture, disability, or Graduate Medical Education Residents or Fellows), or job status changes to limited part-time, casual, or temporary B. At the time of ineligibility, repayment is required for all courses completed within the 12 months prior to the date of ineligibility. C. Repayment will be deducted from the staff member s pay (including vested paid time off payout) and any remaining balance must be paid directly to UPMC. The terminating staff member should contact the UPMC Employee Service Center to arrange for repayment. D. If a staff member repays tuition assistance, and returns to an eligible employment status within one year, the repayment amount is refunded to the staff member. The refund occurs after the staff member remains in an eligible employment status for a period of time equal to the balance of time needed to meet the 12 month employment commitment prior to termination (minimum of 90 days). The staff member must notify the UPMC Employee Service Center when they have met this requirement.

6 XI XII OTHER A. Admission decisions are the sole responsibility of the University of Pittsburgh, community colleges, and technical schools. Eligibility to receive the tuition benefit does not guarantee admission. B. Staff members must be actively employed and meet all other eligibility criteria for the duration of the term to qualify for tuition assistance for their dependent. There may be some exceptions under the enhanced military leave benefit, see HS-HR0712 Military Leave of Absence. C. In the event that these guidelines are inconsistent with the provisions of a collective bargaining agreement, the collective bargaining agreement provisions apply. D. General information on other financial aid opportunities and tuition deferral programs at educational institutions is available from the Employee Assistance Program staff via UPMC DirectLink at 1-800-994-2752, option 6, or in the Employee Assistance Program section of UPMC Infonet and directly from the student s school. E. Staff members who transfer from the University of Pittsburgh and the Veteran s Affairs Medical Center (Oakland) are eligible for tuition assistance, provided their adjusted service dates precede the date of their enrollment in an educational program or course. (See Transfer of Prior Service Credit Policy for a list of those organizations.) F. Tuition cases where credit hours are not utilized by a school, 15 hours of instruction is equivalent to one credit. G. The Plan may recover from you any excess amount reimbursed to you or advanced on your behalf. Future benefits will be paid according to the tuition guidelines, and may be offset by prior overpayment. If you are unsure of your eligible tuition amount, you should contact the UPMC Employee Service Center for verification. H. Questions about the UPMC Tuition Assistance benefit should be directed to the UPMC Employee Service Center at 1-800-994-2752, option 3. APPEAL PROCESS The Employee Service Center has the initial authority to determine whether an individual is eligible to participate and the amount of benefits that are payable. Even though it does not happen often, occasionally questions arise. If a staff member does not agree with a benefit eligibility or assistance amount determination, the staff member should contact the UPMC Employee Service Center to discuss. In most cases, issues are resolved quickly by the Employee Service Center. However, if the staff member still feels the issue is unresolved, there is a written appeal process in place. Refer to the Appeals section of the UPMC Welfare Summary Plan Description for details to submit a written appeal.

7 APPENDIX List of Approved Health-Related Programs For Technical/Vocational Schools Blood Bank Technology/Technician Cardiovascular Technology/Technician Diagnostic Medical Sonography Dialysis Technology Electrocardiograph Technology/Tech Emergency Medical/Paramedic Health Care Technician Health Information Technology Health Prof. & Related Sciences Home Health Aide Massage Therapy Medical Assistant Medical Claims Processing Medical Coding Medical Lab Technician Medical Nutrition/Medical Terminology Medical Office Management Medical Physiology Medical Records Technology Medical Secretary Nuclear Medicine Technology Nurse Nurses Aide Nursing Assistant Occupational Safety & Health Technology/Technician Occupational Therapy Assistant Opticianry/Dispensing Optician Orthotics/Prosthetics Patient Information Coordinator Pharmacy Technician Phlebotomy Physical Therapist Assistant Practical Nursing Radiation Therapy Technology Radiologic Technologist Radiology Department Technology Respiratory Therapist Respiratory Therapy Technician Surgical/Operating Room Technician Medical Transcriptionist