SICK LEAVE POOL DONATION
Date: ______________________________
Last Name: _________________________ First Name: __________________________ MI: _______
Maiden Name (if applicable): _________________________
RE: Donation to the Sick Leave Pool upon My Separation from UWF/Retirement
I wish to donate ______________ hours (up to 16 hours) of my sick leave to the University of West Florida Sick
Leave Pool upon my Separation/Retirement on __________________. I understand that this deduction will be
made from my sick leave balance prior to the processing of any leave payouts (if applicable).
CC: Supervisor
Employee Personnel File
To Be Completed By Sick Leave Pool Administrator
Current Sick Leave Balance: __________________________ as of _____________________________.
Hours Contributed: ____________________
Date Transferred: _____________________
_____________________________________ ____________________________
Sick Leave Pool Administrator Date
Revised: 7/13/2018
