For many University of California academic student employees represented by the UAW, navigating child care expenses while managing academic and work commitments is a substantial challenge. Recognizing this, the UBEN 254 form emerges as a critical resource, offering a structured way for these employees to request child care expense reimbursements. Designed to alleviate the financial burden on academic student employees, this form facilitates access to the Academic Student Employee (ASE) Child Care reimbursement program, outlining eligibility criteria, reimbursement limits, and the necessary process for submission. Not only does it specify the documentation required and the importance of timely submission aligned with academic terms, but it also addresses tax considerations associated with these reimbursements. By ensuring qualified dependents are cared for financially, the UBEN 254 form plays an indispensable role in supporting the academic and professional endeavors of student employees within the University of California system, making it essential for eligible employees to understand and utilize effectively.
| Question | Answer |
|---|---|
| Form Name | Form Uben 254 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | uben254 uben 254 form |
ACADEMIC STUDENT EMPLOYEE (ASE) CHILD CARE REIMBURSEMENT
FOR
UBEN 254 (R1/11) University of California Human Resources
Submit your completed form to your hiring department personnel office.
If you are a UC academic student employee represented by the UAW, use this form to request reimbursement of your eligible child care expenses under the Academic Student Employee (ASE) Child Care reimbursement program. For eligibility, see the Academic Student Employee Factsheet, at atyourservice.ucop.edu/forms_pubs/index. html.
A qualiied dependent is a
A child care provider must have a valid tax identiication or Social Security number.
Deadline
Reimbursement requests for expenses must be submitted after the expenses are incurred. Reimbursement requests should be submitted via this form based on campus speciied deadlines but no later than the last day of the following term.
Payments under this program are subject to Federal, State and FICA taxes, if applicable. Federal tax withholding will be 25 percent and state tax withholding will be 6 percent.
PERSONAL INFORMATION
EMPLOYEE’S NAME (Last, First, Middle Initial) |
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EMPLOYEE ID NO. |
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CAMPUS |
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ADDRESS (Number, Street) |
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HIRING DEPARTMENT |
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HOME PHONE |
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WORK PHONE |
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DEPENDENTS |
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DEPENDENT NAME |
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RELATIONSHIP |
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BIRTHDATE |
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DEPENDENT NAME |
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BIRTHDATE |
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DEPENDENT NAME |
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RELATIONSHIP |
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DEPENDENT CARE INFORMATION |
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DEPENDENT CARE PROVIDER |
TAXPAYER ID NO. |
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DATES OF SERVICE |
AMOUNT OF INCURRED |
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EXPENSES (Attach a copy |
REIMBURSED |
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of documentation) |
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1. NAME |
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$ |
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ADDRESS (Number, Street) |
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FALL SEMESTER |
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SPRING SEMESTER |
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FALL QUARTER |
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WINTER QUARTER |
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2. NAME |
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ADDRESS (Number, Street) |
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FALL SEMESTER |
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SUMMER SESSION |
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FALL QUARTER |
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3. NAME |
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ADDRESS (Number, Street) |
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FALL SEMESTER |
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SPRING SEMESTER |
SUMMER SESSION |
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FALL QUARTER |
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WINTER QUARTER |
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TOTAL AMOUNT TO BE REIMBURSED
EMPLOYEE’S SIGNATURE
I certify that: 1) I have incurred these expenses and have not previously requested payment for them from any source; 2) I have met all the requirements for dependent care expenses (including as required by to the Internal Revenue Code); 3) under penalty of perjury the above information is true to the best of my knowledge.
SIGNATURE (must be an original; not a photocopy)
DATE
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FOR CAMPUS/LOCATION USE |
SIGNATURE |
HIRING DEPARTMENT PERSONNEL OFFICE |
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office signature at right certiies that the form is complete, that the |
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AUTHORIZES PAYMENT TO ASE AND INITIATES |
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employee has/had an appropriate appointment as an ASE and that |
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PAYMENTS FOLLOWING CAMPUS GUIDELINES. |
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applicable documentation is attached. |
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RETN: 5 years |
SEE REVERSE FOR PRIVACY NOTIFICATIONS |
PRIVACY NOTIFICATIONS
STATE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply information about themselves.
The principal purpose for requesting information on this form, including your Social Security number, is to verify your identity, and/or for beneits administration, and/or for federal and state income tax reporting. University policy and state and federal statutes authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even prevent completion of the action for which the form is being illed out. Information furnished on this form may be transmitted to the federal and state governments when required by law.
Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements. Infor- mation on applicable policies and agreements can be obtained from campus or Office of the President Staff and Academic Personnel Offices.
The officials responsible for maintaining the information contained on this form are the Office of the President and campus Academic and Staff Personnel Managers or campus Accounting Offices.
FEDERAL
Pursuant to the Federal Privacy Act of 1974, you are hereby notiied that disclosure of your Social Security number is mandatory. The University’s record keeping system was established prior to January 1, 1975 under the authority of The Regents of the University of California under Article 1X, Section 9 of the California Constitution. The principal uses of your Social Security number shall be for state tax and federal income tax (under Internal Revenue Code sections 6011.6051 and 6059) reporting, and/or for beneits administration, and/or to verify your identity.