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 you have already applied for the UCU national Fighting Fund, enclosing your Fighting Fund reference number (required) 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 Explain the circumstances of your Local Fund claim, (e.g. urgent caring, disability, housing, end of contract or other similar issue 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 periods, these can include payslip(s) demonstrating strike deductions, screenshots from CORE showing strike days or equivolent evidence. Note - you should claim for all strike days in a single Local Fund claim, regardless if your deductions are staggered. If you don't have all payslips yet (due to staggered deductions) please supply a CORE 'My Time' scan showing all days of industrial action you took or equivolent evidence (please also attach your intitial payslip or equivolent evidence showing the first staggered deduction). 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) * note the Local Fund will compensate for all days of industrial action. For the above option, please supply the TOTAL number of days you were on strike, INCLUDING the first 3 days. Total number of strike days you declared/ were on strike (required) 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.