NOTE: PLEASE ATTACH A COPY OF COURSE DESCRIPTION.

To be completed by Employee:
I believe that the graduation level course(s) listed above may be excluded from my gross income under section 162 of the Internal Revenue Code. I certify these courses*:

(1) Maintain or improve skills required in my employment.	Yes	No
(2) Meet the express requirements of my employer, or the requirements of applicable laws or regulations, imposed as a condition of retaining my job, status, or rate of pay.	Yes	No
(3) Are required to meet the minimum educational requirements.	Yes	No
(4) will qualify me for a new trade or business.	Yes	No
* To qualify for income exclusion, a "yes" answer is required for either statement (1) or (2), and a "no" answer is required for both statements (3) and(4).

__________________________________________	________________
Employee Signature	Date

To be completed by Supervisor:
I certify that I have compared the description(s) of the course(s) listed above with the employee’s job description and
agree    disagree    with the above representations made by the employee.

 

__________________________________________	________________
Supervisor Signature	Date