The UC Irvine Emergency Accrued Vacation/PTO Payout Program (“the Program”) is a temporary program offering eligible UCI employees who are experiencing financial hardship as a result of the 2021 wildfires in Orange County, California. The Program allows employees an option to request a one-time payout of up to a maximum of forty (40) hours of their available accrued vacation/PTO hours to help meet expenses incurred due to the impacts of the wildfires.

To apply for this Program, please submit the following completed application and required documentation to your supervisor. Please carefully review the Program guidelines athr.uci.edu.

Employee Certification

By submitting this application I certify that this request for participation in the UC Irvine Emergency Accrued Vacation/PTO Payout Program is made on account of financial expenses I have incurred as a result of the 2021 wildfires in Orange County, California. I also certify that I have included documentation to support my eligibility for the Program. I have read and understood all related program information at hr.uci.edu and agree to the terms and conditions.

Employee certification

Employee Information

Employee Name*

Employee Email Address*

Employee Contact Phone Number*

Preferred Mode of Contact* (check one)
PhoneEmail

UCPath Employee ID Number*
(this can be found on your timesheet, paystub, or atucpath.universityofcalifornia.edu)

Employee Department*

Type of Employee* (check one)
StaffFaculty / other academic personnel

Are you represented?*
YesNo

Supervisor Name*

Supervisor E-mail Address*

Please note the following regarding your payout request

• Your request should be made in whole hours; submission for fractions of an hour will beadjusted down to reflect available whole hours.
• Vacation accrual/PTO payments are taxable as income and subject to all applicablewithholdings and deductions, including taxes and retirement contributions.
• Employees who request a vacation/PTO accrual payout may not revoke the request or“buyback” the hours at a later date for the purposes of restoring the leave balance
• Requests for a vacation/PTO accrual payout that would result in a negative vacation/PTO accrualbalance will be automatically adjusted down to the closest available wholehourincrement the applicant has available in their balance.
• Please be sure to account for any pending or upcoming vacation as the requested hourswill no longer be available for future use.

Requested Number of Accrued Vacation/PTO Hours to be Paid Out

Enter your requested number of accrued vacation/PTO to be paid out (maximum of 40hours)*

Documentation Required for Submission

Proof and/or receipts verifying allowable expenses. Allowable expenses can include:

1. Living expenses such as food, shelter, and clothing;
2. Rent payments, primary residence repairs, or mortgage payments;
3. Assistance with medical insurance, out-of-pocket costs, or co-pays

Employee Authorization

I authorize a payout of the above-requested number of hours from my existing vacation/PTOaccrual balance. If I do not have the requested number of hours available, I authorizeapayout of the closest whole hour increment available. I understand my vacation/PTOaccrualbalance will be reduced by the number of hours I have authorized and those hourswill nolonger be available for use.

Employee certification