Sick Leave Bank Donation Form printable pdf download

Sick Leave Bank Donation Form

Donation Period

October 1, 2015 through December 31, 2015

Your donation of “personal” and/or “annual” leave makes a difference in the lives of fellow State

employees faced with catastrophic illnesses or injuries.

Name: ____________________________________Employee Number: ______________

Department: _______________________________________________________________

Bargaining Unit:

_____ Non-Management

_____ Supervisory

_____ Corrections

_____ Confidential / Managerial

I request transfer of _________ hours of personal leave and/or _______ hours of annual

leave to the Sick Leave Bank. I understand that I may donate up to 100% of my personal leave

balance. I may donate up to 50% of my annual leave balance so long as I retain at least

80 hours of annual leave.

My current leave balances are:

Personal Leave: _____________ Annual Leave: ______________

Employee Signature: _______________________________ Date: ___________________

Human Resources Administrator: _______________________________________________

(or designee of the appointing authority)

Date: ______________________________

Thank you for making a difference!

Please print this form, complete it, and forward it to your Human Resources

Administrator between October 1, 2015 and December 31, 2015.

You may contact your Human Resources Administrator with any questions

regarding donating time to the Bank.

Human Resources Administrators can email the form to: Anne.Carver@vermont.gov

Or, mail to: Human Resources, 120 State Street, 5

Floor, Montpelier, VT 05620-2505

PLEASE NOTE: Donation Forms must be received by December 31, 2015

Sick Leave Bank Donation Form