Services Information

Retraining Assistance Program Reimbursement Request Form

This form is used to submit reimbursement requests for the Retraining Assistance Program (RAP). Sections 1–3 are to be completed by

the employee.

This form must be received by the Acclaris Reimbursement Center no later than 15 months following the date

separation occurred.

Reimbursement services provided by Acclaris

Send completed forms to: Claim Inquiries:

Acclaris Reimbursement Center Please contact us at: 1-888-***-****

PO Box 20571 TTY : 1-877-***-****

Tampa, FL 33622-0571 Web site: www.acclarisonline.com

Fax: 1-813-***-****

Instructions for Submission:

Complete all the requested information on this form.

Make sure your signature is at the bottom of the form.

NOTE: Requests will not be reimbursed for courses/services that have not been completed.

Requests cannot be reimbursed until all required information is received.

Requests must be submitted within 15 months of your separation date or the claim will not be reimbursed.

The following supporting document must be included with your form when filing for reimbursement:

Copy of proof of payment

Full itemization of fees

Copy of the verification of completion

(Please print clearly using blue or black ink.)

1. To be completed by employee

Name and home address to be completed with each submission (Please Print)

Employee Name (Last, First, Middle Initial) Employee Serial Number Employee Social Security Number Separation Date

Street Address City State Zip Code

2. Reimbursement Request Information

Name & Address of Institution/Instructor Name of Course/Service Provided Start Date of Course End Date of Course

If applicable, please check the following regarding course taken: Total Charges

Home Study: Online Course (added to plan on March 1, 2007):

I certify that the information above and submitted with this form is accurate.

I certify that the statements in this application are correct and that I have incurred the expenses reflected in the attached bills or receipts.

To all providers of services associated with this reimbursement: You or your representatives are authorized to obtain or view a copy of my records

pertaining to expense information necessary to determine eligibility for reimbursement of the claim submitted. A copy of this authorization shall be as

original.

Reimbursement for Overpayment:

I hereby agree to notify the Acclaris Reimbursement Center if I become aware of any overpayment of this claim and to reimburse Acclaris promptly for

any amount by which a claim payment is finally determined to have exceeded the applicable benefit.

3. Only an employee is authorized to sign this form.

Employee’s/Retiree’s Signature Date Former Work Location/Division Phone Number

Rev. 12/07 3.IM-B-470K.102

Contact this candidate