Mcpr 2001 Appendix K Sick Leave Donor Authorization Form printable pdf download

MCPR, 2001

APPENDIX K, SICK LEAVE DONOR PROGRAM AUTHORIZATION FORM

MONTGOMERY COUNTY GOVERNMENT

Sick Leave Donor Program Authorization Form

To be completed by employee or another acting on employee’s behalf:

Name: __________________________________ Title: ______________________________

(Please print)

Department: _____________________________ Division: ___________________________

Work schedule: Full-time: ___ Part-time: ___ If part-time, how many work hours per week? ___

Work phone: _____________________________ Home phone: _______________________

Please read the information below. (See Section 17-10 of the Personnel Regulations for more

information about the Sick Leave Donor Program.)

If you received a pay advance, as reflected on your payroll check, those advanced hours

will be paid off by your initial grant of donated sick leave. This will cause the payroll

check containing the initial grant of donated sick leave to be less than a full check. This

Finance Department policy was established to prevent any overpayment of salaries

beyond the end of the time sheet certification. The Payroll Section will give you further

notice of this adjustment before it sends you the affected payroll check. If you have

questions about this, please call the Payroll Section, at 240-777-8840.

The Director of the Office of Human Resources may revoke a leave donation to an

employee, declare an employee ineligible for leave donations for up to one year, or

recommend discipline to the employee’s department director, if the employee:



gives false or misleading information on a form associated with the Sick Leave Donor

Program; or



attempts to intimidate, threaten, or coerce another with respect to donating,

receiving, or using sick leave or PTO under the Sick Leave Donor Program

Complete this form, the Sick Leave or PTO Donation Request Form, the Medical

Certification Form for Sick Leave or PTO Donations, and send the forms with a copy of

the approved leave request (if in written form) to the Payroll Section. Payroll must

receive all required forms no later than the Monday following a payday to ensure that

you receive a paycheck based on the donated leave on the next payday.

Please fax or send the forms (fax is preferred) to: Payroll Section, Attention: Sick Leave

Donor Program, 101 Monroe Street, 8th Floor, Rockville, Maryland 20850. (Fax 240-

777- 8843 and phone 240-777-8840)

Signature of employee or

person signing for employee: ___________________________ Date: __________________

If employee did not sign form, please indicate below your relationship to employee and phone

number(s) where you may be reached:

____________________________________________________________________________

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Mcpr 2001 Appendix K Sick Leave Donor Authorization Form