DEADLINE: every 1st of the Month
PSAC Local 610
Western University
1313 Somerville House
London, ON, N6A 3K7
ph: (519)661-4137, fax: (519)850-2998
e-mail: staffpsac610@gmail.com
web: www.psac610.ca
Financial Assistance Application
Please
read the instructions carefully. Incomplete applications will not be considered.
Mission Statement: The Financial Assistance Fund exists to assist the financial needs of members when all other avenues have been
exhausted,
with the following categories: Medical Emergencies, Personal Emergencies, Academic/Conference Travel, and Child Care
Subsidy.
Eligibility: To apply you must have held a teaching assistantship for at least one term in an academic year (for TAs on leave, exceptions
may be granted). Applicants must be members of the local at the time of the expense. Please submit one application form per
deadline per member. You may apply for all applicable categories on one form.
Application Review: Applications are considered throughout the year. Please allow time for a response from the committee. The
committee aims to respond to all applications within one month of the deadline. Applicants will be notified of decisions by email, and
if your application has been successful, you can pick up your cheque at the Local's office.
The terms divide into Summer (June 1st-August 1st), Fall (September 1st-December 1st) and Winter (January 1st-April 1st). An
academic year runs September 1st- August 31st. Application adjudication periods divide occurring to the months in the calendar
(1st-31st). Should the expense claimed exceed the allotted $500 within a single term, the applicant may apply in the next term for the
remainder of the same expense. However, new and previously unfunded claims take precedence.
Confidentiality: Each application is assigned an identification number and reviewed by the Financial Assistance committee without
any personal information.
Please see page 2 of this application for an overview of each category and the Financial Assistance FAQ for further information.
Instructions: Please be specific about the need for which you are applying. General living expenses will not be considered. Any
information which you can provide will greatly help the committee in making a decision about your claim. Please provide receipts for
the expenses already spent by the applicant. We only accept applications with receipts.
Contact Information:
Name:
UWO email:
Department:
Student #:
Program:
Address:
Program Starting Date:
Street number and name:
Apt#:
City: Province/State:
Postal Code:
For Office Use Only
ID:
Date Received: Initials:
I hereby certify that the information provided in this application is complete and accurate.
Signature:
Date:
click to sign
signature
click to edit
Claim Categories
Applications must be filled out in full to receive consideration. The Financial Aid Committee will verify the receipts appended to
the application. Only documented expenses for which receipts are included shall be considered. While the committee has the
authority to fund or deny any application, the following criteria express the committee's preferences.
Unlikely to be funded: Petcare expenses / Passport fees, Visa applications or permanent residency fees / Vehicle expenses / UHIP
expenses / Textbook purchases, tuition fees / Technology purchases, unless these can be explicitly justified / Conference fees or
membership
fees / Any other expenses that does not qualify as "unexpected need".
1)Medical Emergencies (maximum $500 per term)
This category covers all the unexpected medical expenses. You may also claim for a dependent, such as a child, spouse or
parent. These include emergency medical or dental bills, including bills incurred outside Canada.
Please ensure you have applied for and exhausted your eligible SOGS health plan and PSAC 610 EHP benefits. If the expense was
not covered by SOGS, then put "0" in the "covered by SOGS" column. However, you need to explain and provide document proof
why it was not covered by SOGS. If your receipt is covered by SOGS and you have not yet applied for reimbursement then you
must first apply to SOGS.
This category covers any expenses related to the care of a dependent (children, spouse, common-law-partner) including medical
expenses and day care costs. If dependent is not a child, spouse, or common- law-partner, please provide sufficient proof such as
a tax return where he/she is declared as a dependent.
2)Personal Emergencies (maximum $500 per term)
This category covers all unexpected expenses other than regular household costs. To apply in this category, the applicant must
provide substantial documents to support their claim. The application will be reviewed by the committee on the basis of what is
submitted. Please ensure you include receipts and a rationale for the emergency.
Examples of eligible funding include but are not limited to: bereavement travel expenses, financial difficulties related to
separating from a spouse or partner and the loss of property due to an unforeseen catastrophe (house fire, flood, etc.) Know that
the Financial Aid Committee values your privacy. Any personal information shared with the committee is kept confidential.
3)Academic/Conference Travel (maximum $300 per academic year)
This category covers expenses related to academic work and/or conferences for applicants who are not fully funded for the
costs
by another source. Please provide supporting documents, such as a letter from supervisor/department or proof of funding of that
was sought but not approved. The applicant must also provide documentation of their conference
registration, travel and lodging
expenses, and proof of participation as a presenter such as an itinerary of conference. We strongly encourage you at also apply
for the SOGS Travel Subsidy.
4)
Child Care Subsidy (maximum $500 per academic year)
This category covers expenses related to child care costs. Please enclose the appropriate documentation and receipts with your
application. Only receipts from licensed childcare providers and programs will be considered for the subsidy. For a list of licensed
child care providers, go to http://www.iaccess.gov.on.ca/LCCWWeb/childcare/search.xhtml. Members are also encouraged to
apply to SOGS Child Care Subsidy.
For Office Use Only
ID:
Date Received: Initials:
Please outline your (and your household's) annual income sources and the approximate amounts. Income sources include fellowships,
assistantships, grants, bursaries, and work outside of the university. Income from other investments should also be included. Report your
income and expenses for the current academic year (September- August).
You must fill out all the information. If any of the criteria is not applicable to you then please put "0 (zero)". No further opportunity will
be given to update your application once the reviewing process has started. If you have any questions about filling out the application,
please contact the office.
Section 1) Applicant Information
Are you an international student?
Yes
No
Income Source
Fall Term Winter Term Summer Term TOTAL/YEAR
Teaching Assistantship
Research Assistantship
University or Department Funding (WGRS, WES)
Scholarships (NSERC, SSHRC, OGS, OGSST, IGSS, etc.)
Please specify which:
Other Income (e.g. off- campus employment)
Please specify which:
1.
Subtotal:
Section 2) Household Information
Do you have Spouse/Common-Law-Partner?
Yes
No
Immigration Status:
International PR/Canadian
If yes please fill out the following information:
Income Source
Fall Term Winter Term Summer Term TOTAL/YEAR
Spouse / Common-Law-Partner Income
If any of the above does not apply to you please put "0" in the corresponding section.
2.
Subtotal:
Are your dependents (spouse/common-law-partner or children) enrolled in SOGS Health Plan?
Yes
No
Do your dependents have external health care plans other than OHIP/UHIP?
Yes
No
If you have answered "yes" to the above, and you are applying for a medical expense, please attach the insurance statements.
Current Academic Year Expected Income
Section 3) Dependent Information
Do you have children?
Yes
No
How many children do you have?
If yes please fill out the following information for all your children, if no please skip to section 4:
Income Source
Fall Term
Winter Term
Summer Term TOTAL/YEAR
Canada Child Benefit (CCB)
Daycare Subsidy
If any of the above does not apply to you please put "0" in the corresponding section.
3.
Subtotal:
Section 4) SOGS Funding
Please indicate below the financial programs and scholarships which you have already applied for to meet your need. If you have not done
so already please consider applying for these bursaries if they are applicable.
Income Source
Fall Term Winter Term Summer Term TOTAL/YEAR
Child Care Subsidy
Emergency Loans
Travel Subsidy
Ontario Student Opportunity Trust Fund
SOGS Bursary (Grad Club Bursary/Out of Province
Bursary/125th Anniversary Scholarship)
Section 5) PSAC 610 Funding
4.
Subtotal:
Income Source
Fall Term Winter Term Summer Term TOTAL/YEAR
Extended Health Plan
Financial Assistance
Fund
Mental Health Fund
Food Support & Resources Fund
5.
Subtotal:
GRAND INCOME TOTAL from all of your income sources: (Subtotal of section 1-5)
Medical Emergency
Personal Emergency
Academic/Conference Travel
Child Care Subsidy
Please report your approximate expenses for the current academic year (September-August).
You must fill out all the information. If any of the criteria is not applicable to you then please put "0 (zero)". No further opportunity will
be given to update your application once the reviewing process has started. If you have any question about filling out the application,
please contact our office.
TOTAL/YEAR
Expenses
Rent/Mortgages and Household Utilities
Groceries and food related expenses
Transportation
Child Care Expenses
Tuition fees (including UHIP, SOGS Health Plan and other ancillary fees) and Books and
School Material
Other expenses including loans, etc.
GRAND TOTAL from all of your expenses:
Plea
se select your Financial Assistant Fund category (select all that apply) and complete the appropriate section accordingly:
Medical Emergency Personal Emergency
Academic/Conference
Child Care Subsidy
Total Amount Claiming
describe, in detail, the nature of the need for which you are seeking support. Normally, general living expenses (rent, telephone,
etc.) will not be considered. If your expenses exceed your income by a substantial amount, please provide explanation about how
cover those extra expenses. Attach an additional page if necessary. You may attach additional pages. Please do not write your name.
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You must fill out all the information. If any of the criteria is not applicable to you then please put "0 (zero)". No further opportunity will
be given to update your application once the reviewing process has started. If you have any question about filling out the application,
please contact our office.
Type of Expense Date Total Cost
Amount
Covered by
SOGS
Amount
Covered by
EHP / FA
Amount
covered by
Department
Amount Claiming
TOTAL AMOUNT CLAIMING
Document Check List:
(Incomplete application will not be
processed)
Completed Application Form
Receipts for Expenses
Any other Supporting Documents
GTA Contract Letter if not already on file in the office
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