APPENDIX L SICK LEAVE OR PTO DONATION REQUEST FORM

Name of employee to receive donations: __________________________________________   Last 4 digits of Soc. Sec. No.:_________

                        (Please print)

Form submitted by:____________________________________________________________   Date: _____________________________

                  (Name & work phone)

Employee eligibility to donate sick leave or PTO.

1.   A full-time employee must maintain a sick leave or PTO balance of 80 hours after donation. A part-time employee who works 40 hours or more in a pay period must maintain a sick leave or PTO balance of 40 hours after donation. A part-time employee who works less than 40 hours in a pay period must maintain a pro-rated amount of unused sick leave after donation.

2.   An employee must not donate sick leave or PTO after giving oral or written notice of retirement or resignation or receiving written notice of separation from County employment.

I/We hereby donate sick leave or PTO to the above named employee in the amounts indicated in accordance with the eligibility requirements of the Sick Leave Donor Program.

Dept.       Donors            Last 4 digits of    Donors         Donors                  Hours

Code      Name            Soc. Sec. No.      Work phone      Signature               Donated

________   ______________________   ____________   __________________   _______________________________________   __________

________   ______________________   ____________   __________________   _______________________________________   __________

________   ______________________   ____________   __________________   _______________________________________   __________

________   ______________________   ____________   __________________   _______________________________________   __________

________   ______________________   ____________   __________________   _______________________________________   __________

Use additional sheets, if necessary. See Section 17-10 [33.07.01.10] of the Personnel Regulations for more information about the Sick Leave Donor Program.