Staff Assembly Assistance Request Form

The Staff Assembly Assistance Program tries to provide assistance to UCR staff members needing support. Please complete this form and submit it to apply. All requests for assistance are kept confidential. Staff assembly will only assist in the form of gas and/or grocery store gift cards. These gift cards should be used to offset the cost of the actual area of assistance need.

Eligibility Requirements

Any UCR career appointment status employee is eligible to request assistance. The staff member must have completed the probationary period. A valid employee identification number is required.

All requests for assistance must fall under the guidelines of the UCR Catastrophic Leave Program. For information about the UCR Catastrophic Leave Program guidelines, please go to the following website:

https://hr.ucr.edu/policies-and-procedures/personnel-policies-local-procedures

Limitations on Assistance

Staff assistance is provided in the form of gas and/or grocery store gift cards. Direct cash assistance is not provided through this program. The maximum amount of assistance is limited to a value of up to $100 per employee, per fiscal year (July 1 to June 30).

1. Please provide the following information:

First Name *This question is required.

Last Name *This question is required.

Payroll Title *This question is required.

Home Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Postal Code *This question is required.

Country

Email Address *This question is required.

Phone Number *This question is required.

Company Name

Fax Number

Mobile Phone

URL

2. Amount Requested: *This question is required.

3. Please explain in detail your situation and why you are requesting assistance. (This information will be kept confidential) *This question is required.

4. Have you requested assistance for Staff Assembly in the past? *This question is required.

Yes
No

When have you received assistance in the past? *This question is required.

Staff Assembly Assistance Request Form

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