Attachment J

Employee details

Name

Job

Political office holder and portfolio

Employee number

Phone number

Study course details

Name of course/qualification

Name of university/education provider

Year I am applying for study assistance (Note: Applications   need to be made in the year the course of study is being undertaken.)

Subjects I am enrolled in for this year’s terms/semesters:

Enrolment status (complete if you are undertaking a university course). Select one option.

 Commonwealth supported student

If yes, attach Commonwealth Assistance   Notice

OR

 Local full fee paying student

If yes, are you (select one option):

 Paying upfront

OR

 Deferring payment through   FEE-HELP loan

Previous financial study assistance   applications and results

Have you previously received   financial study assistance?

 Yes                     No

If yes, attach supporting evidence of   successful completion (only include results you have not   previously reported)

Financial details

I am aware that:

•   I may   apply for up to $6,000 or the equivalent of 100% of the education costs,   whichever is the lesser amount.
•   If I do   not successfully complete the course/s, I will need to repay the financial   assistance.
•   If I terminate my employment, I will need to repay any financial assistance received in the previous 12 months.

I am seeking assistance to the total   amount of:

$

Specified costs:

HECS-HELP

$

STUDENT FEES

$

COURSE FEES

$

RECOMMENDED/COMPULSORY BOOKS & MATERIALS/OTHER

$

REPAYMENT OF FEE-HELP LOAN

$

Payment/reimbursement options   (select one option)

If approved, I request payment of study   assistance

  In advance by cheque made payable to:

_______________________________________________

OR

  By cheque to me as reimbursement for costs   already incurred in the current year (receipts attached).

Office approval (by Political office   holder OR Chief of Staff)

The study will contribute to and not   be detrimental to the employee’s performance

The employee has attached evidence   of enrolment, receipts and other relevant documents

Funds are available from the   Political office holder’s budget

Cost centre

GovConnect Human Resources

Receipts attached

        Yes              No

Calculation correct

        Yes              No

Prepared by

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