Form Rs 6221 - Statement Of Accrued Payments And Leave Credits Page 2
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25. LUMP SUM PAYMENT(S)
PLEASE LIST ALL TYPES OF PAYMENTS SEPARATELY. ENTER NA IF NOT APPLICABLE.
DAYS
PAYMENT AMOUNT
PAYMENT DATE
(Enter in days not hours)
A. LUMP SUM VACATION
____________________ $ ____________________
_____________________
B. LUMP SUM OVERTIME*
____________________ $ ____________________
_____________________
C. LUMP SUM SICK LEAVE
____________________ $ ____________________
_____________________
D. LUMP SUM HOLIDAYS
____________________ $ ____________________
_____________________
E. LUMP SUM LONGEVITY
____________________ $ ____________________
_____________________
(If prorated give dates)
____________________
F. OTHER PAYMENTS
(EXAMPLES – BALANCE OF CONTRACT, RETROACTIVE PAYMENTS, VACATION BUY BACK OR PAYMENT
FOR UNUSED SICK LEAVE).
TYPE OF PAYMENT
DATES COVERED
PAYMENT AMOUNT
PAYMENT DATES
____________________
____________________ $ ____________________
_____________________
____________________
____________________ $ ____________________
_____________________
____________________
____________________ $ ____________________
_____________________
____________________
____________________ $ ____________________
_____________________
____________________
____________________ $ ____________________
_____________________
*PROVIDE TIME PERIOD THAT LUMP SUM OVERTIME PAYMENT APPLIES TO
6. IS EMPLOYEE ON OR HAVE THEY BEEN ON WORKERS COMP DURING THE PAST THREE YEARS
(5 YEARS TIERS 2, 3, 4)?
Yes
____
No
_____
(Please check one)
7. HAS EMPLOYEE BEEN GRANTED AN APPROVED MEDICAL LEAVE OF ABSENCE SINCE THE LAST DATE PAID?
Yes
____
No
_
____
(Please check one)
IF YES, DATE LEAVE BEGAN AND ENDED.
______/_____/________
thru
______/_____/________
(MM)
(DD)
(YYYY)
(MM)
(DD)
(YYYY)
8. WHO MAY WE CONTACT WITH QUESTIONS ABOUT THE INFORMATION SUBMITTED ON THIS FORM, IF
OTHER THAN AUTHORIZED SIGNATURE?
________________________________________
_________________________________
NAME
TELEPHONE NUMBER
I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM AND AFFIXED TO FORM CLEARLY IDENTIFIES
ALL TYPES OF PAYMENTS MADE TO
_________________________________________________________
____.
RETIREE’S NAME
________________________________ ______________ ______________________ _______________________
AUTHORIZED SIGNATURE
DATE
TITLE
TELEPHONE
PLEASE COMPLETE BOTH SIDES OF THIS FORM IN ITS ENTIRETY AND SIGN
RS 6221 (Rev 7/09)
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