REQUEST TO DONATE LEAVE
___________________________________ ______________________________
Employee’s Name Department
I wish to donate___________hours of my accrued annual leave.
I wish to donate___________hours of my accrued sick leave.
My signature below certifies that:
1. My paid annual leave balance as of date below is__________________ hours.
2. My paid sick leave balance as of date below is____________________ hours.
3. I have read and abided by CSC’s Leave Sharing Policy.
4. The leave that I am requesting to donate will not place my accrued paid leave
balance below 160 hours.
5. I am donating this leave voluntarily of my own free will.
____________________________________ ______________________________
Employee’s Signature Date
(Office use only)
Donor’s annual leave balance is ________on _____________. Verified by ___________
(Today’s date) Initials
Donor’s sick leave balance is ________on _____________. Verified by ___________
(Today’s date) Initials
APPROVED DISAPPROVED
Comments:______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
____________________________________ _____________________________
Human Resources Director Date
Revised 2/11/2016
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