UM Human Resources Department

Scholarships, Fellowships, Bursaries, Research Grants & Trustee Payment

(Please click here for Explanatory Notes)
Type of Assistance:

Reason for submitting the form:

A. Personal Information:

Salutation:

Surname:

Given Name(s):

Employee Number:

Social Insurance Number:

Gender:
Male Female

DOB
(yyyy/mmm/dd)

Has employees home address changed since the last form has been sent to HR for them?
Yes No

Student Status:

Section B. Position/Funding Information

Faculty/Unit:

Department:

Note: Funding information in the ‘Old Funding Information’ section should mirror exactly your last form for the assistance, with the exception of the ‘new end date’ field & the ‘new max to be paid’. See explanatory notes for more information on this section of the form.
Old Funding Information
                          Previous           New                  FOP from prior form                   Old Max             New Max
Start Date          End Date          End Date          Fund      Org       Prog    Account  Amount Payable Amount Payable
(yyyy/mmm/dd) (yyyy/mmm/dd) (yyyy/mmm/dd)
FOP From Prior Form And Max Amount Information:
       

Current Funding Information:

FOP-AMOUNT Data Entry Format:

Calculation Based on Total or Annual Amount?

C. Attachment (Please check as appropriate - secure with a staple or binder clip to prevent loss)
Work Permit
Award Letter From Granting Agency
Resignation Letter
Original Form
Direct Deposit Authorization
TD1 Form (if recipient chooses to increase tax deduction through Payroll)
Comments:

This form is prepared by:

Phone: Date: