CATASTROPHIC LEAVE BANK PROGRAM
DONOR APPLICATION FORM
PLEASE TYPE OR
PRINT LEGIBLY. (Au
thorized by Act 169 of 1991)
Instruction: Co
mplete this form to donate accrued Annual or Sick Leave to the Agency’s Catastrophic Leave Bank
Program. An employee’s accrued Annual or Sick Leave cannot be reduced to less than eighty (80)
hours (except upon termination). Accrued Leave may be donated in hourly increments of no less
than one (1) hour. After completing Parts I and II, forward to employing agency’s Human
Resource/Payroll Office.
PART I - COMPLETED BY DONOR
Name of Donor (Last, First, Middle Initial) Position Number T Number
Amount of Annual Leave Hours Donated Amount of Sick Leave Hours Donated Total Amount of Leave Hours Donated
CERTIFICATION OF VOLUNTARY DONATION:
I certify that I am making this donation entirely of my own free will and that no attempts have been made to
intimidate, threaten or coerce me to donate my Annual or Sick Leave. I understand that I have no right under any
circumstances to have any of the donated Leave restored to my accrued Annual or Sick Leave totals. I further
certify that I am a regular/full-time employee of
agency and I am being
compensated on a full-time basis. I further certify that this Leave Time Donation will not reduce my combined
annual and sick leave balance to less than eighty (80) hours (except upon termination).
Signature of Donor
Date
PART II - COMPLETED BY DONOR’S TIMEKEEPER
Annual Leave Hours Balance After Donation
Sick Leave Hours Balance After Donation
Timekeeper’s Name
Timekeeper’s Signature Phone Number Effective Date of Balance
PART III - COMPLETED BY AGENCY INTE
RNAL PERSONNEL/DIRECTOR
Employment Status
□ Full-time
□ Retirement
□ Termin
ation
Total
Leave Hours Donated Hourly Rate of Pay Dollar Value of Donation
Signature of Agency Internal Personnel Representative
Date
PART IV - APPROVAL OF AGENCY/INSTITUTION DIRECTOR/DESIGNEE
Signature of Authorized Agency/Institution Director/Designee
Date
PART V - RETURN TO AGENCY/INSTITUTION PERSONNEL OFFICE
R FOR PROCESSING
PART VI - COMPLETED BY CLB RECORD KEEPER
Credit Date for Donated Leave
Signature of CLB Record Keeper
ATU-013
2/05
