PERALTA COMMUNITY COLLEGE DISTRICT
LEAVE BANKING PROGRAM APPLICATION
College: __________________________________________________ Date: _________________________
1. Request for: ___ Banked Hours ___ Use of Banked Hours (Leave) ____ Cash-out Banked Hours
2. Documented Critical Hardship Emergency
1
___ Yes ___ No
3. Nominal Residual Balance
2
___ Yes ___ No
4. Instructor’s Name: ___________________________________ SS#: _________________________
5. Term Applied for: __________ Beginning: __________ Ending: __________
6. Number Of Hours To Be Banked Or Cashed Out: Semester Equated Hours: _____ Summer Equated Hours: _____
7. Instructor’s Signature: _____________________________________ Date: _________________________
(DEAN’S OFFICE USE)
8. Status: ___ Tenured ___ Probationary. Indicate Contract FTE During Current School Year: _____________________
9. Date Last Banked Leave Taken/Paid: ____________________________________________________________________
10. Number Of Hours Used Or Cashed Out: _________________________________________________________________
11. Balanced Of Banked Hours: ___________________________________________________________________________
12. Budget Code To Be Charged (For Banked Hours Only): _____________________________________________________
13. Initial Date Of Hire (Seniority): ________________________________________________________________________
14. Rate Of Pay (Pro-Rata Schedule): _______________________________________________________________________
15. Verified By: _____________________________________________ Date: _________________________
16. Approved: ___ Disapproved: ___ (For Taking Leave Only)
17. Dean: ________________________________________________________ Date: _________________________
18. Vice President: ________________________________________________ Date: _________________________
19. College Business Officer: ________________________________________ Date: _________________________
20. Vice Chancellor For Finance & Admin: _____________________________ Date: _________________________
21. Reason For Disapproval: ______________________________________________________________________________
22. Remarks: __________________________________________________________________________________________
23. Entered And Recorded By: _______________________________________ Date: _________________________
Distribution: Personnel, Payroll, Dean, Vice President, Business Officer
CONVERSION FACTORS
To convert semester equated hours to quarter equated hours multiply by 1.5
To convert quarter equated hours to semester hours multiply by .667
To convert summer semester hours divide by (3).
To convert summer quarter hours divide by (2).
1
"Documented critical financial emergencies" shall include one of the following
documented events occurring within the six months preceding the request to cash out:
death of unit member
death in their immediate family
bankruptcy foreclosure divorce
birth or adoption
retirement, termination, resignation, or permanent disability of the unit member, or their spouse or domestic partner.
Documentation must be submitted to the Vice Chancellor of Finance.
For any other documented critical financial emergency (not listed above), such as a serious medical emergency in the immediate family, documentation shall
be submitted to both the PFT President and the Vice Chancellor of Finance, and the Vice Chancellor shall make the final decision as to whether the
documented critical financial emergency meets the criteria of IRS Code 1.451-2 (Constructive receipt of income), after consultation with the PFT President.
2
Nominal residual balances are defined as remaining balances of $2,500 or less.
Form Created September 17, 2012
