Third-Party Payment Notification Form

Please note: To avoid a late fee of $150, please complete this form before the billing due date to show how your bill will be covered. This form must submitted each semester. This form is only open for the current term. This form will open for future terms after the bills are available for that term. You cannot complete this form before the bills open for a future term.

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 of scholarships to post to your account.

Student Information

RU Student ID (e.g. @00123456)

RU Email Address

First Name

Last Name

Enrollment Information

Term

Source of Funding

Please indicate source of funding.

Employer Benefits/Tuition Reimbursement - PROOF OF ELIGIBILITY IS REQUIRED, must show approved amount

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

Honeywell MOU - No documentation needed.

529 Tuition Savings payment - PROOF OF WITHDRAWAL IS REQUIRED

Other (Workforce Investment, Full Employment Council, etc.) - PROOF OF ELIGIBILITY IS REQUIRED

Funding Organization Information

Funding Organization

Contact Name

Contact Phone Number

Contact Email

Additional Information

Proof of Eligibility (HR tuition payment policy, supervisor approval, LOC, authorization, etc.)

Amount to be paid from source of funding

Additional Information

Proof of withdrawal from account

Amount of withdrawal

Does Rockhurst need to invoice this organization?

Yes

Will your organization pay Rockhurst directly or reimburse you directly?

Reimburse me

Pay the University

Special instructions for billing, if applicable:

Acknowledgements

Students must read and initial each of the following statements 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.

Signature

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