Request For Payment Of Leave Balances For Employees Approved For Long Term Disability Form
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1REQUEST FOR PAYMENT OF LEAVE BALANCES
FOR EMPLOYEES APPROVED FOR LONG TERM DISABILITY
When an employee is approved for LTD, all annual leave, compensatory hours and excess hours are paid out in
one full lump sum payment unless the employee submits a written request to delay the payout until separation
from State employment, which usually occurs six months after the last day worked. The employee’s disability
check will not be adjusted as a result of this payout regardless of when the payout is received. If the employee
returns to work prior to one year after the last day worked, the employee has the option of buying back any
annual leave paid out.
If the employee has Converted Sick Leave hours still remaining upon approval of LTD, the employee has the
option to receive a payout of the hours upon LTD approval, delay the payout until separation from State
employment, or retain the balance until the employee retires for use in purchasing health/life insurance or a
Medicare Supplement.
Sick leave balances may not be paid out at any time.
(To be completed by Employee)
□
I wish to receive a lump sum payment of my leave balances NOT including Converted Sick Leave
hours at the time of LTD approval.
I wish to receive a lump sum payment of my leave balances INCLUDING Converted Sick Leave
□
hours at the time of LTD approval. □ Program I □ Program II
□
I wish to defer the lump sum payment of my leave balances until my medical leave of absence
has expired and I am separated from State employment.
________________
________________________________________ ________
Employee Signature
Date
(To be completed by Human Resource/Payroll representative)
Employee Name:___________________________________ Employee ID#: ______________
Agency: __________________________________________ Loworg: ____________________
Job Title: _________________________________________ Rate of Pay: ________________
LTD Effective Date: _________________________________Separation Date: _____________
Leave balances available for payout at time of LTD approval:
Annual Leave Hours __________ Program I Converted Sick Leave __________
Excess Leave Hours __________ Program II Converted Sick Leave __________
Comp Leave Hours __________
Total Leave Hours to be Paid Out _________ X _________ = $______________
(Rate of Pay)
(Lump Sum Payout)
Date of Payout: __________________
______________________________________________
______________________
HR/Payroll Representative Signature
Date
(Revised 9/21/10)
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