Application Form And Declaration Parental Leave

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Human Resources
Application Form and Declaration Parental Leave
This form is to be completed when the period of the parental leave
is definitely established. After being signed by the immediate superior you can
hand in this document to the P-officer of your faculty or department.
A. Details staff member
Name:
Initials:
Employee number:
Civil service number:
Faculty/Department:
Employed from:
B. Details child for whom parental leave is requested
Name:
First names:
Date of birth:
C. Parental leave
c.1) Based on the parental leave scheme you can divide your parental leave into a maximum of 3 periods,
whereby each period lasts at least one month. With the number of hours you fill in the number of hours
you actually continue to work per week, i.e. not the hours of leave.
Period ( A ) from:………………… untill……………actual number of hours to work per week:……..
Period ( B ) from:………………… untill……………actual number of hours to work per week:………
Period ( C ) from : ……………… untill……………actual number of hours to work per week:………
c.2) Hours of parental leave, which in the previous years have been saved under the Optional Model
Employment Conditions, to be debited from the leave card: …….hours.
These hours will be taken up in the period:………………………………….
c.3) In the calendar year (calendar years) in which your parental leave has been planned, do you also save
(money) under the Life-course Savings Scheme and you wish to (partly) use your life-course credits to
finance the unpaid part of the parental leave?
Please circle the applicable answer:
calendar year 2012 YES or NO calendar year 2013 YES or NO calendar year 2014 YES or NO
If in a calendar year you have answered a question with yes for your income tax return you can qualify for a parental leave tax
credit
D. Signature
By signing this form you agree to the provisions as laid down in the “Partly Paid Parental Leave Scheme
Dutch Universities 2007”. In particular you are referred to article 5, paragraph 5, of this scheme. If you
resign within six months after expiry of the parental leave or your employment is terminated owing to
circumstances attributable to you, you are obliged to pay back the partially paid salary.
Signature staff member
(signature) ……………………… (name) ………………….. (date) …………………………
Immediate superior: ................................................
(signature) ……………………….(name)………………
…...(date)………………………..
Head Salary Administration …………………………………………………………………
J.A.J. de Bot (Phone: 053-4892188) date……..……………….

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