Third Party Notification Form

This form indicates any Third party payments (Employer, VocRehab, Workforce Initiative, 529 payments, etc.) you are expecting. This form is not for students to reflect scholarships for payment. Please notify Financial Aid to post your scholarship amount. If your scholarship company needs an invoice please email us at studentaccounts@rockhurst.edu.

Student Information

First Name

Last Name

Birthdate

RU Email Address

Rockhurst Student ID (example: @00123456) Please enter @00 and your six digit ID number

Term

Program

Source of Funding

Please indicate source of funding.

Employer Benefits/Tuition Reimbursement - PROOF OF ELIGIBILITY IS REQUIRED (Approval from employer showing amount approved for the term)

Vocational Rehabilitation (VocRehab) - No documentation needed. Official Vendor Invoice provided by VR

Workforce Investment - PROOF OF ELIGIBILITY IS REQUIRED

Full Employment Council - PROOF OF ELIGIBILITY IS REQUIRED

Other non-scholarship payment - PROOF OF ELIGIBILITY IS REQUIRED

529 Tuition Savings payment - PROOF OF WITHDRAWAL IS REQUIRED

If you selected other please enter the name of your source funding.

Please attach the required Proof of Eligibility or Withdrawal. (i.e., employer HR tuition reimbursement policy, supervisor approval via email or written document, etc.)

Funding Organization Information

Funding Organization

Name of contact person

Contact phone number

Contact Email Address

Contact Mailing Address

Country

Street

City

Region

Postal Code

Does Rockhurst need to invoice this funding organization?

Yes

No

Will your organization pay Rockhurst directly or pay you (reimburse you after the term)?

Pay me (remember, you must pay the University within 30 days after the term ends).

Pay the University

Special Instructions for billing

Covered Charges

Amount requested for tuition, fees and supplies (including books) for this term:

Acknowledgements

Student must read and initial each of the following statement of understanding:

I understand a statement/receipt can be obtained via the student portal or will be provided upon request.

I understand that should my company be unable or refuse to pay any or all of my tuition for any reason, the remaining balance on my student account is my responsibility.

I understand that withdrawal from the College voids this agreement. New balance as a result of withdrawal calculation becomes due immediately and must be paid in full.

I understand that any portion of tuition and fees not covered by my third party is due by payment due date or a $150 late fee will be assessed on my account.

I understand that official transcripts and diplomas will not be released. In addition, registration for future classes may be restricted if full payment is not made by the due date.

I, the undersigned, hereby authorize Rockhurst University Student Accounts Office to disclose any necessary educational data/information related to receiving funding from the above agency/organization. I understand that the records information related to receiving funding may contain data that is classified as private under the Federal Family Education Rights and Privacy Act. I understand by signing the Informed Consent Form that I am authorizing Rockhurst University Student Accounts Office to release or receive information that would otherwise be private and not accessible to them. I understand that without my consent, such information could not be released. This consent expires upon completion of agency funding, or after one year, whichever comes first. I am giving this consent freely and voluntarily, and I understand the consequences of giving my consent.

By signing below, you agree to the following:

Any portion of tuition and fees not covered by a third party is due by the due date.
You are ultimately responsible for all tuition and fees.
The total account balance is due 30 days after the semester has ended for payments being sent from an employer. This does not apply to 529 payments.

Third Party Notification Form

RESOURCES

I WANT TO:

SCHOOLS