Paid Time Off Donation Request Form Page 2

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Paid Time Off Donation Policy Example:
[Company name] has created a way for employees to donate unused PTO to a charitable organization to encourage and
promote its employees in their philanthropic endeavors. [Company name] will convert up to _______ hours of an employee’s
unused PTO to cash per year, which will be sent via check to a charitable organization of the employee’s choice. [CONVERSELY
THE COMPANY CAN DESIGNATE ONE OR A FEW CHARITABLE ORGANIZATIONS TO WHICH THE EMPLOYEE CAN DONATE. THIS
IS OFTEN THE CASE IF THE COMPANY IS ONLY MAKING THE POLICY AVAILABLE FOR DISASTER RELIEF EFFORTS, FOR
EXAMPLE.] Eligibility requirements are below.
In order to request a PTO donation, please complete the PTO donation form and have it signed by your supervisor.
Proof of donations will be noted on the employee’s pay stub, and may be used as a charitable contribution for personal tax
purposes. Converted PTO is subject to all the same employer and employee payroll taxes as the employee’s salary and will be
reported on the employee’s W-2.
Eligibility:
Donors:
• All [company name] active, part- or full -time regular employees are eligible to participate in the PTO donation program.
• An employee may only donate PTO when they have accrued over ______ weeks. Only PTO that is over ______ weeks
may be donated so that the employee has enough PTO left in case they need or want it.
• The maximum amount of PTO an employee can donate per [DESIGNATED TIME FRAME] is ______ hours.
PTO Donations:
• The organization/project receiving the donation must be a public educational institution; or tax-exempt 501(c)(3) nonprofit
organization as recognized by the Internal Revenue Service.
• The organization/project being funded must have a nonreligious primary purpose.
• The organization/project may not discriminate against race, religion, gender or creed.
• The gift may not be used for such purposes for which donors, their families or other individuals designated by the donor
receives a direct benefit; this includes payment for services, tuition, books and student fees.
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2440 West El Camino Real, Suite 300 | Mountain View, California 94040 | 650.450.5400 |

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