Form Annex E-2 - Payment Request Form - 2015-2016
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1MN National Guard Circular 621-5-1
Annex E-2
1 July 2015
PAYMENT REQUEST FORM
EXTENDED STATE TUITION REIMBURSEMENT
MINNESOTA NATIONAL GUARD
2015-2016
-----DATA REQUIRED BY THE PRIVACY ACT OF 1974-----
AUTHORITY: Minnesota Statute 192.501 Financial Incentives for National Guard Members
PRINCIPAL PURPOSE: To request tuition reimbursement through the extended state tuition reimbursement (E-STR)
program.
ROUTINE USES: To confirm eligibility requirements for the E-STR program and determine amount of reimbursement.
INSTRUCTIONS: Upon course completion, complete this form, attach grade report and final fee statement and submit to
the education services office. The form must arrive at the education services office no later than 90 days after the last
official day of your course/ term. Payment requests submitted after 90 days will be returned without action or payment.
DISCLAIMER: The funding available for the E-STR program is limited by an appropriation set by the state legislature.
Payment is dependent upon the continuation of the program and availability of funds.
_________________________________________________________________________________________
Name: _______________________________________________________________SSN: _________________________
Current Mailing Address: ______________________________________City: __________________________State:______
Zip Code:___________Preferred Email: _______________________________________ Phone:_____________________
Degree type (check one):
Enter number of credits completed:
_____Undergraduate/graduate certificate
_____Summer II (Jul/Aug 2015)
_____Associate
_____Fall
_____Baccalaureate
_____Winter
_____Master’s degree
_____Spring
_____Professional degree (i.e. J.D., D.C., M. Div.)
_____Summer I (May/Jun 2016)
_____Doctorate (i.e. Ph. D.)
Total Number of Credits Attempted: _____ Credits Eligible for Reimbursement: ____ Tuition Charged: $_____________
Note: Fee statement or letter from the school must reflect the actual amount of tuition charged.
My Minnesota Direct Deposit Authorization for EFT form is currently on file or attached (Annex D-1). ______ (initial)
Did you receive any federal GI Bill payments (not including Minnesota GI Bill) which were paid directly to the
institution?
Yes
No If YES, what was the amount of payment $________________ What percentage of
tuition was paid directly to the school by federal GI Bill this term? ____%
Did you receive an ROTC scholarship which directly paid tuition to the institution for this school term (do not
include room and board scholarship amount)?
Yes
No If YES, what was the amount $________________ (Do not report room and board scholarship)
Remarks:
I understand the directives outlined herein and in MN National Guard Circular 621-5-1 and my responsibilities
for participation in the Minnesota State Tuition Reimbursement program.
______________________________________________________
____________________________
SIGNATURE
DATE
ANNEX E-2 EXTENDED STR PAYMENT REQUEST FORM
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