UCU UoL Local Fund Claim Form For problems using this form, please alternatively email the branch office, including all the above details/ attachments at email@example.com Your Full Name (required) UCU membership number (required) Your Email (required) Your Telephone Number (required) Other Telephone Number (optional) Confirm if you have already applied for the UCU national Fighting Fund (please ignore this field if FF is not available in this action), enclosing your Fighting Fund reference number. Note - you are able to make an application in advance of your FF claim. Note for casualised or sessional staff: if you are unable to complete the FF application or do not have access to UoL systems such as CORE please leave this box blank and outline any difficulties evidencing strike action in the text/message box at the end of this form. Your Residential Address (required) Contract Type PermanentFixed TermFixed Term ending in more than 3 monthsFixed Term ending in 3 months or lessOther (please explain contract below) ARPS (academic related and professional services PT members) Confirmed is a PT ARPS staff member How are you paid? MonthlyWeeklyHourly paidOther - please explain below Note on Assessment Boycott period - The university has stated that it will suspend deductions for the marking and assessment boycott from 18/06 to 23/07 (so no boycott deductions have arisen at this time), please factor this in any LF claim until further notice. Phase(s) of the industrial action in this claim, e.g. Strike Action of 24-05-21 to 11-06-21, 04/08/21 to 14/08/21. It can be useful to make a separate claim for distinct/different industrial actions(s), e.g. if you have different circumstances/multiple evidence uploads for specific action(s). However to make a claim for a number of different actions as a single claim, please use the last 'custom' option shown below and explain the various actions you are applying for in the text box below, also show the total days for all actions in the 'number of days you were on strike' field below. 24-05-21 to 11-06-21Boycott from 18-06-21 (not applicable due to suspended deductions)04/08/21 to 14/08/21Custom - describe all actions in text box Explain the circumstances of your Local Fund claim, (e.g. urgent caring, disability, housing, casualised/end of contract status, or other reason which would otherwise cause detriment). Here only the essential details are needed (required), however please also include at least one document, file or scan in the later attachments section below related to this reason, e.g. bill/invoice/letter documenting an issue you are describing, this is for our auditing purposes. If you are unable to provide such documentation please indicate if you are unable to provide documentation, but outline the basis of your claim in the box below. Please attach evidence of strike action below, these can include payslip(s) demonstrating strike deductions, screenshots from CORE showing strike days or equivalent evidence. Note if you do not have evidence of action (e.g. casualised, sessional staff or other reason) please simply submit your claim and briefly describe your difficulty in evidencing days of action in the text box above. If possible please supply a CORE 'My Time' scan showing all days of industrial action you took or equivalent evidence (or attach similar evidence such as an email showing action taken). Please attach any document/email/invoice/bill etc. indicating the basis of your local fund claim if possible. File attachment 1, suggested formats are PDF, JPG, PNG (required) File attachment 2, suggested formats are PDF, JPG, PNG (optional) File attachment 3, suggested formats are PDF, JPG, PNG (optional) Please supply the number of days you were on strike for strike action/phases in this claim INCLUDING the first 3 days. Rates available: you can specify a lump sum of your choice. For the lump sum, please indicate desired funds required from £50-£350 in £50 increments, e.g. if you require £50, £100, £150 etc. Additional support beyond above rates is also available for urgent and imminent need, for further amounts please explain any additional needs in the text box above. Please list additional sums and clarify the total sum you are seeking (you can add any lump-sum claimed below to your total in the textbox above). If this claim is for a lump-sum please specify your required amount below (£50-£350): UCU strike funds cannot compensate you funds above deducations you have sustained. Please confirm you will not receive more than the total loss from combined applications to UCU-accredited funds: (*Required to proceed) I confirm I am claiming only funds deducted from my salary, i.e. no more than the total loss from my combined applications to UCU-accredited funds.