Donor'S Vacation/sick Pay Transfer Form For Catastrophically Ill Employee Form - Office Of The Controller
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1Office of the Controller
City and County of San Francisco
Payroll/Personnel Services Division
T.J. ANTHONY CATASTROPHIC ILLNESS PROGRAM (CIP)
Donor's Vacation/Sick Pay Transfer Form for Catastrophically Ill Employee
Donor must retain at least 64 hours of sick leave credits
Donor Conditions:
Donor must not be catastrophically ill
CAT ILL PPE
REC. I.D. #
__________________________
_____________________
•
•
Transfers must be in units of 8 hours
Once transferred, all donations are irrevocable
Transfer Conditions:
A maximum of 160 hours per pay period, 80 hours per
Leave credits may be transferred to the CIP
•
•
individual CIP employee, and 480 hours per fiscal year
individual recipient or pool once per pay period
•
•
may be transferred
Donations are subject to the San Francisco
Marital status declaration of spousal consent must be
Administrative Code, Section 16.9-29A
•
completed below
•
I have read and understand the above conditions. I declare under penalty of perjury that I have not and will not
solicit or accept any compensation, directly or indirectly, for the leave hours I am transferring. I further declare that
I am transferring the leave hours of my own free will and not under threat or coercion by any individual.
I choose to transfer
hours of SICK PAY CREDITS and/or
hours of VACATION CREDITS to:
Donor’s Name (please print): __________________________________________________________________________ DSW: _____________________
Individual Recipient Identification Number (RIN):
or
CIP Pool
City Department: _________________________________________________________________________________ 3-letter Dept. Code: ____________
Donor’s Signature: _______________________________________________________________________ Date: _____________________________________
I, ___________________________________________________________________________, declare under penalty of perjury that: (check one)
Marital Status Declaration:
I am not married
PRINT NAME
I do not know, and have taken all reasonable steps to determine, the whereabouts of my current spouse
My current spouse and I have executed a marriage settlement agreement pursuant to Title II of Part 5 of Division 4
of the California Civil Code (or a predecessor statute, if applicable) which makes my earnings my separate property.
Donor’s Signature: _______________________________________________________________________ Date: _____________________________________
I, ______________________________________________________________________, declare under penalty of perjury that I am the legal
Or Spousal Consent:
PRINT NAME
spouse of _________________________________________________________, and I have been informed of my spouse's transfer of
DONOR’S NAME
vacation and/or sick leave credits as an irrevocable donation to a City employee designated as catastrophically ill,
and I hereby consent to this transfer by my spouse.
Spouse’s Signature: _______________________________________________________________________ Date: ____________________________________
TO ENSURE CONFIDENTIALITY, send the original directly to the attention of payroll:
San Francisco Unified School District
Office of the Controller
SFUSD EMPLOYEES ONLY:
ALL OTHER CITY EMPLOYEES:
135 Van Ness Ave. Rm. 101, SF, CA 94102-5207
Payroll/Personnel Services Division
One South Van Ness Ave. 8
Floor, SF, CA 94103
th
S.F. Community College
OR
33 Gough St., SF, CA 94102-1214
DONOR: keep a copy of this form for your files, and provide a copy to your department payroll supervisor.
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Parent category: Medical