General Information
I hereby certify that the above information and all information presented regarding my request for assistance is correct. I understand that any deliberate misrepresentation or withholding of facts will be considered fraudulent and will be grounds for disqualification. If I am requesting assistance based on lost wages and I receive sick leave donations, I understand that I must immediately notify the Benevolent Fund because this could greatly impact my assistance award. Failure to notify the Benevolent Fund of such donations is considered fraud.
I acknowledge that through my application to the UAB Benevolent Fund’s Employee Emergency Assistance Program (EEAP), I am agreeing to allocate any funds provided to me as directed by the EEAP Committee to best assist me and my qualifying situation. The specific allocation of the assistance will be provided after the committee’s decision is made.
I acknowledge that any assistance provided to me through the UAB EEAP will be direct deposited to me through the same means as my pay from the University of Alabama at Birmingham. If I am paid through another UAB entity (Callahan, VIVA, HSF, HS), I will provide information to be set up as a UAB supplier and provide a good address to which the check will be mailed. In either case, it will take 3-4 days to process the request.
I understand that any assistance provided to me through the UAB EEAP is considered taxable income by the IRS and must be claimed as such on my income taxes.
I understand that I must provide receipts verifying the assistance award was applied as approved. I will provide the receipts to the EEAP office no later than 1 month following the receipt of my award. I further understand that it is my responsibility to provide receipts and the EEAP office will not contact me if I fail to provide receipts. Failure to provide requested receipts to the EEAP office will be taken into consideration if assistance is requested from EEAP in the future and will be reason for denial of future requests.
I understand that employees receiving EEAP are required to complete at least 1 financial counseling session with the UAB Employee Assistance and Counseling Center and develop a balanced budget. It is my responsibility to provide a certificate or letter of completion and a balanced budget to EEAP. Failure to provide documentation to the EEAP office will be taken into consideration if assistance is requested from EEAP in the future and may be reason for denial of future requests to the Benevolent Fund. To schedule your financial counseling appointment, please contact UAB’s Employee Assistance & Counseling Center at 205.934-2281.
I understand that this form is being completed in advance of my case being presented to the committee and a determination has not been made regarding financial assistance. This form does not in any way indicate that financial assistance will be awarded to me.