Fillable Application to Withdraw from and/or Change Leave Donation (City University of New York)

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Application to Withdraw from and/or Change Leave Donation (City University of New York)

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Office of Human Resources Management
University Benefits Office
395 Hudson Street, 5th Floor
New York, New York 10014
Tel: 646-664-3357
Fax: 646-664-3418
Application to Withdraw from and/or Change Leave Donation to the Catastrophic Sick Leave Bank
Program
I. To be Completed by the Employee
If you wish to withdraw from participation in the Catastrophic Leave Bank Program or change your leave
donation, please complete and sign below:
Name ________________________________________ CUNYfirst ID: * _________________________
Home Address _______________________________________________________________________
Title: __________________________________________
Campus: ____________________________________ Department: _____________________________
* If you don’t know your CUNYfirst ID, please contact your College Office of Human Resources.
I wish to withdraw- pleas
e sign: _____________________________________
I wish to change my donation to: ______ day(s) of annual leave each program year.
I wish to change my donation to: ______ day(s) of sick leave each program year.
P
LEASE NOTE THAT YOUR DONATION OF SICK LEAVE MAY ADVERSELY IMPACT YOUR TRAVIA OR
TERMINAL LEAVE BENEFIT. YOU ARE ADVISED TO CONSULT WITH YOUR COLLEGE OFFICE OF
HUMAN RESOURCES.
Please return this application to your College Office of Human Resources before the end of the open enrollment
period.
For Employees Who Elect To Change Their Leave Donation to the Catastrophic Sick Leave Bank Program
I hereby acknowledge and understand that my decision to donate sick leave and/or annual leave to CUNY’s
Catastrophic Sick Leave Bank is irrevocable and that the donated leave will not be returned to me, unless it is
determined that I am ineligible to donate leave.
I also acknowledge and understand that my College’s Office of Human Resources will continue to make
automatic deductions as specified herein from my time and leave accruals on an annual basis provided that I
maintain eligibility and have not withdrawn from the CSLB Program or made any changes during an open
enrollment period to the type or amount of leave to be donated.
I further acknowledge and understand that I have not been coerced nor am I receiving any benefit express or
implied, in return for the donated sick leave and/or annual leave, other than my ability to participate in the bank;
and that my donation may impact my Travia or Terminal Leave Benefit.
Employee Signature: __________________________________ Date: ______________________
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For Employees Who Elect to Withdraw from the Catastrophic Sick Leave Bank Program
I acknowledge and understand that by submitting this election to withdraw from the Catastrophic Sick
Leave Program to my Office of Human Resources, I will no longer be covered by the Catastrophic
Sick Leave Bank Program for the current program year (September 1 –August 31) and thereafter,
unless I re-enroll during an open enrollment period. I further acknowledge and understand that my
decision to withdraw from the Catastrophic Sick Leave Bank Program for this program year is
irrevocable.
Employee Signature: ________________________________ Date: ________________________
II. To Be Completed by the College Human Resources Director or Designee
Signature of College Human Resources Director or Designee:
Name (Print): ________________________________
Signature: ____________________________________ Date: ___________________
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Application to Withdraw from andor Change Leave Donation (City University of New York)

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Completed 18 December 2020

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