Orange County Pay Period Affidavit

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Orange County Pay Period Affidavit
Department:
to
1/12/1900
Employee #:
Employee Name:
Court/Jury/Wi
Date
Vacation
Sick Leave
FMLA (S/V/L)
Parental
Catastrophic
Bereavement
tness
Military
Other
12/30/1899
12/31/1899
1/1/1900
1/2/1900
1/3/1900
1/4/1900
1/5/1900
1/6/1900
1/7/1900
1/8/1900
1/9/1900
1/10/1900
1/11/1900
1/12/1900
0
0
0
0
0
0
0
0
0
Totals
Employee Certification:
I certify that I have read the foregoing application/affidavit and I have requested the time off as indicated, for the reasons shown, in full conformance with all Orange
County policies and procedures governing the same. I understand that any intent to misrepresent the information in the application/affidavit could result in disciplinary
action and/or termination. I further state that I am entitled to all time herein claimed and I further understand that any deficiencies in all time herein claimed will result
in the withholding of same time from any future compensation to which I may be entitled.
Employee Signature:___________________________________________________________________________
Official/Department Head Approval/Disapproval:
I have read the foregoing application/affidavit and have granted the time off, as requested, in conformity with all Orange
county policies and procedures governing the same.
_______
_______ I have read the foregoing application/affidavit and have not granted the time off as requested, for the following reason(s):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Therfeore, employee is to be docked________hours.
OFFICIAL / DEPT. HEAD SIGNATURE:_______________________________________________________________
NOTE: A physician's certification or note shall be required for any sick leave absence exceeding three (3) days at one time.

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