Vacation And Sick Leave Reporting Form For Teacher Members
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1VACATION AND SICK LEAVE
46 State House Station
Augusta, ME 04333-0046
REPORTING FORM
Telephone (207) 512-3100
FOR TEACHER MEMBERS
Toll-free: 1-800-451-9800
TTY: (207) 512-3102
Member Name: ___________________________________________ Social Security Number ________________________
Employer Name: __________________________________________ Employer Code: ______________________________
Reason for this report:
Service Retirement
Disability Retirement
Death
Instructions for completing this form can be viewed and/or downloaded at:
TERMINATION INFORMATION
1. Termination Date: ____/____/________
LEAVE INFORMATION
2. Maximum accrued leave allowed for employees in this classification:
Sick Leave _____________ Days
Hours Vacation Leave ____________
Days
Hours
3. Amount of leave accrued at point of termination by this employee:
Sick Leave _____________ Days
Hours Vacation Leave _____________
Days
Hours
FINAL PAY INFORMATION
4. Employee’s rate of pay: $____________
Daily
Hourly
5. Date of final monthly payroll detail report on which employee will appear: ____/________ (month/year)
6. Unused sick leave pay (do not include pay for sick leave taken/used):
$________________
Date Paid: ____/____/________
7. Unused vacation pay (do not include pay for vacation leave taken/used):
$________________
Date Paid: ____/____/________
DISABILITY RETIREES ONLY
8. Last Day in Pay Status: ____/____/________
DO NOT list a date when the member was paid from a sick leave bank.
9. Hourly Employees Only:
Number of hours this employee was expected to work per day: __________Hours/Day
All Employees:
Number of days per week this employee was expected to work: __________Days/Week
Number of weeks per year this employee was expected to work: __________Weeks/Year
CERTIFYING SIGNATURE
I certify that the above is the true and correct representation of the final earnings of the above-named employee and does not
include: any vacation or sick leave unless that leave was earned in the course of regular employment; any amount paid as a
retirement stipend, an incentive to retire or a consideration for notice of a planned retirement; any amount paid as a bonus; or
any other payment that is not compensation for actual services rendered or is not paid at the time services are rendered. I
recognize that any misrepresentation or omission may result in the delay of the payment of retirement benefits to this
employee and may be subject to the MainePERS statutes regarding fraud [Section 17105(1) (D)].
____________________________________________
_____________________________
___________________
CERTIFYING OFFICIAL: Signature
Title
Date
____________________________________________
_____________________________
___________________
Printed/Typed Name
Phone #
E-mail
Form #CL-0050
PLEASE RETAIN A COPY FOR YOUR RECORDS
Rev. 6/08
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