EmailMe Form - Graduate Student Emergency Fund Request Form

Caltech UID *

Name *

First Last

Email *

Option *

Contact Phone *

### - ### - ####

Amount requested *

$ Dollars . Cents

Please provide a brief explanation of the request below. *

Attach any supporting documentation. Bills and/or invoices must contain a date of service, and in cases of medical or dental charges any insurance applied (if applicable). Personal medical information may be redacted for privacy. If requesting funds for a theft, please include a police report or case number.

Are you requesting a reimbursement or direct payment? *

Reimbursement of expenses I have paid or plan to pay myself

Direct payment on my behalf

If your request is approved, please note that additional information may be required if you are requesting direct payment.

For medical and dental requests, have you consulted with HR Benefits?

Yes

No, I am not covered under Caltech's insurance plan