DONATED LEAVE FOR CATASTROPHIC ILLNESS (CONTRIBUTIONS) PART A. TO BE COMPLETED BY THE DONATING EMPLOYEE: I donate a hours of my accrued vacation total of leave to: (For UE/IUP donating employees only) donate a hours of my accrued leave as total of follows: comp. holiday comp. time banked holiday time, and/or, time to: employed by (Recipient) (Recipient’s Department) understand that this contribution of my accrued leave is irrevocable and cannot be reversed or changed once it is credited to the RECIPIENT. (Signature of Donating Employee) (Date) PART B. TO BE COMPLETED BY THE DONATING EMPLOYEE’S HUMAN RESOURCES ASSOCIATE: Donor’s Last 4 Digits Name: of SSN: Payroll #: (Signature of Human Resources Associate ) (Date) Human Resources Associate: Please forward a copy of this form to the RECIPIENT’S Human Resources Associate. A copy of this form will be returned to the donating employee’s Human Resources Associate when the donation is credited to the RECIPIENT. PART C. TO BE COMPLETED BY THE RECIPIENT’S HUMAN RESOURCES ASSOCIATE: Recipient’s Last 4 Digits Name: of SSN: Payroll #: Form AND Received: (Date) (Time)
DONATED LEAVE FOR CATASTROPHIC ILLNESS (CONTRIBUTIONS) PART A. TO BE COMPLETED BY THE DONATING EMPLOYEE: donate a total of hours of my accrued vacation leave to: (For UE/IUP donating employees only) donate a total of hours of my accrued leave as follows: comp. time, holiday comp. time and/or, banked holiday time to: employed by (Recipient) (Recipient’s Department) I understand that this contribution of my accrued leave is irrevocable and cannot be reversed or changed once it is credited to the RECIPIENT. (Signature of Donating Employee) (Date) PART B. TO BE COMPLETED BY THE DONATING EMPLOYEE’S HUMAN RESOURCES ASSOCIATE: Donor’s Name: Last 4 Digits of SSN: Payroll #: (Signature of Human Resources Associate ) (Date) Human Resources Associate: Please forward a copy of this form to the RECIPIENT’S Human Resources Associate. A copy of this form will be returned to the donating employee’s Human Resources Associate when the donation is credited to the RECIPIENT. PART C. TO BE COMPLETED BY THE RECIPIENT’S HUMAN RESOURCES ASSOCIATE: Recipient’s Name: Last 4 Digits of SSN: Payroll #: Form Received: AND (Date) (Time)
552-0612_donated_leave_contribution.docx