CITY OF MERIDEN PAYOUT OF ACCRUED TIME FOR THE PURPOSE OF
RETIREMENT/RESIGNATION/DEATH
NAME:
DEPARTMENT:
UNION:
Date of Retirement, Resignation, Etc.
Reason for Termination (Check one)
Retirement Resignation Death Other (Specify)
Hourly Rate of Pay:
Hours Worked Per Week:
Accrued Maximum Time Allowed by Contract Amount to be Paid
Comp Time Hours:
Earned Time Hours:
Vacation Time Hours:
Sick Time Hours:
Q Time Dates: from to
TOTAL PAYOUT
Account Number, if different from regular salary line:
Prepared By:
Department Head
Date:
Risk Manager
Date:
Human Resources Director
Date:
Please note any employee with Q time in their pay record in the last 5 years
prior to resignation/retirement/termination must have severance signed by Safety
and Risk as well as Personnel.
Also, please forward a copy of this form to MIS to terminate e-mail and
computer access.
Payout of Accrued Time
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