COVID PTO Request Form

COVID-19 PTO Request Form
We are excited to share that, once again, Carewell SEIU 503 is offering COVID-19 Paid Time Off benefits to workers impacted by the pandemic.

You can receive up to 40 hours of paid time off benefits if:
- you lose hours after January 1, 2021 for one of the five qualifying reasons below, and
- you worked at least 40 hours in one of the three months before the time period in which you lost those hours. For example, if you lose hours in February, you would need to have worked 40 hours in either January 2021, December 2020, or November 2020 to be eligible.
The five qualifying reasons for lost hours are:
1. You had a confirmed case of COVID-19;
2. You were advised by a qualified medical professional to self-quarantine due to potential exposure to COVID-19;
3. You have symptoms of COVID-19 and are actively seeking a medical diagnosis by a qualified medical professional;
4. You are providing care for an individual, who you are legally responsible for or live with, and who is subject to a quarantine or isolation order by a qualified medical professional; and/or
5. You are caring for a child who you are legally responsible for whose school or childcare facility has been closed due to COVID-19 precautions and no other qualified individuals are available to care for your child(ren).
Complete this form to apply for the COVID-19 PTO benefit.
Name *

First Name Middle Name Last Name
Provider number *
Date of birth *

Month Day Year
Date
Phone number *

Area Code Phone Number
Cell or landline? *

Cell phone Landline
Email
example@example.com
Mailing address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is your mailing address the same as your physical address? *

Yes No
Physical address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

I am requesting the following number of hours of COVID PTO benefit *
Enter the total number of COVID PTO hours you are requesting; no more than 40.
for *

Month Day Year
Start date for the period that you lost hours; must be after 1/1/2021.
through *

Month Day Year
End date for the period that you lost hours; must be after 1/1/2021.
I lost work hours because of COVID-19 (check one that applies): *

I had a confirmed case of COVID-19 I was advised by a qualified medical professional to self-quarantine due to potential exposure to COVID* I have symptoms of COVID-19 and am actively seeking a medical diagnosis by a qualified medical professional* I am providing care for an individual, who I am legally responsible for or live with, and who is subject to a quarantine or isolation order by a qualified medical professional* I am caring for a child who I am legally responsible for whose school or childcare facility has been closed due to COVID-19 precautions, and no other qualified individuals are available to care for my child(ren)
*In order to qualify for this benefit, “advice or an order to quarantine due to COVID-19” must have been issued by a qualified medical professional.
By signing below, I certify that the above reason for my request is true and accurate. I understand that by completing and signing this form I am requesting a taxable income benefit. I also understand that I will not receive payment for this Paid Time Off benefit unless I have submitted a Form W-9 to the Benefits Administrative Office. If either the covered hours that I worked or the covered hours that I missed can’t be verified, I understand that I may be responsible for paying the benefit back. *

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Con mi firma a continuación, certifico que la razón anterior de mi solicitud es verdadera y exacta. Comprendo que al diligenciar y firmar este formulario estoy solicitando un beneficio de ingreso gravable. También comprendo que no recibiré el pago derivado de este beneficio de tiempo libre remunerado, a menos que haya presentado un Form W-9 (Formulario W-9) ante la Benefits Administrative Office (Oficina Administrativa de Beneficios). Comprendo que si no se pueden verificar las horas cubiertas que he trabajado o las horas cubiertas perdidas, podría verse obligada a devolver el beneficio. *

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Своей подписью я удостоверяю верность и точность указанной мною причины запроса. Я понимаю, что заполнение этой формы и подпись под ней означают запрос денежной льготы, подлежащей налогообложению. Я также понимаю, что не получу выплату по льготе в виде оплачиваемых отгулов, если не подам Form W-9 (форму W-9) в Benefits Administrative Office (Административный офис по льготам). Я понимаю, что Если невозможно проверить ни оплачиваемые отработанные часы, ни потерянные часы, то Я может быть обязан вернуть полученную сумму. *

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Bằng việc ký tên vào phần dưới đây, tôi xác nhận rằng lý do tôi yêu cầu ở trên là đúng và chính xác. Tôi hiểu rằng thông qua việc điền thông tin và ký tên vào mẫu đơn này, tôi đang yêu cầu phúc lợi dành cho thu nhập chịu thuế. Tôi cũng hiểu rằng nếu không nộp Mẫu Đơn W-9 cho Văn Phòng Quản Lý Phúc Lợi, thì tôi sẽ không nhận được khoản thanh toán cho phúc lợi Thời Gian Nghỉ Được Trả Lương này. Tôi hiểu rằng nếu không thể xác minh số giờ được bao trả mà bạn đã làm hoặc số giờ được bao trả mà bạn bị mất, Tôi lợi có thể phải chịu trách nhiệm trả lại phúc lợi. *

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通过在下方签名，我保证上述申请的原因真实准确。我了解，通过填写并签署此表格，我正在申请一项应税收入福利。我也了解，除非我已向福利管理办公室提交 Form W-9（W-9 表格），否则我将不会收到此带薪假福利的付款。 *

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COVID-19 PTO Request Form