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Please complete this form and “submit” it electronically below. If you have any questions, please don't hesitate to contact a a HERS team member

Account Service Request Form

Institution:
Department:
Institution Contact Name:
Phone:
Email:
Aproximate number of Rooms:
New Hire Name:
Spouse/Partner's Name:
New Position:
Current Home Phone:
Cell Phone:
Current Email:
Current Residence Address:

Street:
City:
State:
Zip:
Comment:
Destination Address:
Street:
City:
State:
Zip:
Comment:
Anticipated Relocation Date:
Standard School/department policy applies: * Yes No
Or total dollar limit budget to new hire:**

*If we have your Institutions standard relocation policy on file and it will apply for this new hires relocation, you do not need to complete the balance of this form. If unsure, please indicate services authorized or maximum dollar allowance.

All HERS program service benefits, resources and discounts will apply regardless of whether the institution or the affiliate is paying relocation expenses. Home Marketing/Purchase assistance is a no cost value add HERS program benefit and will automatically be offered to your employee as appropriate, or as specified by your institutions internal programs.

All relocation services checked below are authorized, up to allowance amount (if applicable). If an allowance has been stated, affiliate will be counciled on budgeting and any balance beyond the allowance will be at their expense (payable on service delivery via cash, certified check or credit card). For your convenience, taxable benefits are noted with an asterik below.

If a dollar limit applies, please indicate up to a $ allowance.
Post hire Area Familiarization Tour (fee based)*
Half day custom tailored tour
Full day tour

Temporary Housing* up to days or $*

Spouse/Partner Career Counseling (fee based)*
Yes No

Rental Assistance (fee based)*
Yes No

Household Move including:
Packing Materials
Yes No

Packing Material delivery to residence
Yes No

Extra stops
Yes No

Full Packing Service
Yes No

Packing of fragile only
Yes No

Full Unpacking Service
Yes No

Unpacking of Mattresses only
Yes No

Packing material debris pick-up (included in unpacking service)
Yes No

Crating/Uncrating Service
Yes No

Extra Stops at other than Primary residence
Yes No
(# authorized)

Appliance/Fixture Servicing/disconnect reconnect
Yes No

Auto Transportation up to
Yes No
vehicle

Bulky items:
Pianos: Yes No
Riding Mowers: Yes No
Big Screen TVs: Yes No
Boats/Canoes: Yes No

Storage up to 30 days *
Yes No
Storage beyond 30 days
Yes No up to days*

Pet Transportation:
Yes No

Settling In Services (assistance with completion of local registration or legal documentation paperwork; residence preparedness extras i.e. maid service, window treatment installation, etc.) *
Yes No

Laboratory Relocation Project Management - please complete a Lab Relocation Project Management Service Request Form Yes No

*Taxable benefits which must be reported as additional income to your employee if paid for or reimbursed by your institution. For more information about Tax compliance issues visit www.irs.gov/pub/irs-pdf/p521.pdf.