State of INTERAGENCY SICK LEAVE TRANSFER REQUEST TO DONATE Part I - Request Sick Leave Hours -or Information I certify that I have read and understand the requirements and provisions of Rule 60L-34.0042(5), F.A.C., and that I am eligible and willing to donate my personal sick leave credits as specified below. I further understand that the donated sick leave credits will be permanently deducted from my sick leave balance at the end of the pay period and if unused, will be returned. Print Name: People First Employee ID#: Agency/Division/Bureau or District/Region/Institution: Work Telephone Number: ( ) I authorize my employer to transfer hours of sick leave to the following recipient (minimum of 8 hours). I certify that I am related to the recipient by birth, marriage or other legal relationship, as specified in Rule 60L-34.0042(5)(b), F.A.C., (spouse, parents, grandparents, brothers, sisters, children and grandchildren of either the employee or the spouse). Signature Date RECIPIENT INFORMATION Recipient's Name: People First Employee ID# (if known): Agency/Division/Bureau or District/Region/Institution: Part II - For Personnel Office(s) Use Recipient's Agency Donor's Agency Date: Date: Send To: Send To: Sick Leave Transfer (SLT) Plan Administrator SLT Plan Administrator Personnel Resources Personnel Office/Human Resources Department of Department of Telephone: Fax: Telephone: Hours Credited: PPE: Fax: Hours Credited: PPE: Hours Charged: PPE: Hours Credited: PPE: Approved Disapproved Hours Credited: PPE: SLT Administrator's Signature: _____________________ Approved Per Criteria Disapproved Per Criteria Print SLT Administrator's Name: SLT Administrator's Signature: ______________________ To return unused sick leave to the donor, complete Part III of this form. Print SLT Administrator’s Name: DMS-SLDONATIONTEMPLATE Rev. 10/15
State of INTERAGENCY SICK LEAVE TRANSFER REQUEST TO DONATE Part I - Request Sick Leave Hours -or Information I certify that I have read and understand the requirements and provisions of Rule 60L-34.0042(5), F.A.C., and that I am eligible and willing to donate my personal sick leave credits as specified below. I further understand that the donated sick leave credits will be permanently deducted from my sick leave balance at the end of the pay period and if unused, will be returned. Print Name: People First Employee ID#: Agency/Division/Bureau or District/Region/Institution: Work Telephone Number: ( ) I authorize my employer to transfer hours of sick leave to the following recipient (minimum of 8 hours). I certify that I am related to the recipient by birth, marriage or other legal relationship, as specified in Rule 60L-34.0042(5)(b), F.A.C., (spouse, parents, grandparents, brothers, sisters, children and grandchildren of either the employee or the spouse). Signature Date RECIPIENT INFORMATION Recipient's Name: People First Employee ID# (if known): Agency/Division/Bureau or District/Region/Institution: Part II - For Personnel Office(s) Use Recipient's Agency Donor's Agency Date: Date: Send To: Sick Leave Transfer (SLT) Plan Administrator Personnel Resources Send To: SLT Plan Administrator Personnel Office/Human Resources Department of Department of Telephone: Fax: Telephone: Hours Credited: PPE: Fax: Hours Credited: PPE: Hours Charged: PPE: Hours Credited: PPE: Approved Disapproved Hours Credited: PPE: SLT Administrator's Signature: _____________________ Approved Per Criteria Disapproved Per Criteria Print SLT Administrator's Name: SLT Administrator's Signature: ______________________ To return unused sick leave to the donor, complete Part III of this form. Print SLT Administrator’s Name: DMS-SLDONATIONTEMPLATE Rev. 10/15
SL_Donate_frmFinal_10-15.docx