VACATION DONATION PROGRAM
CONTRIBUTION FORM
To be eligible to donate to an employee on the Vacation Donation Program, an employee must be eligible to accrue
and use vacation leave or have a personal leave balance, and must have an earned balance that equals or exceeds
the number of hours donated. Note: Faculty or other personnel who do not accrue vacation may donate personal
leave days.
Al
l state employees may contribute to the following two Vacation Donation Programs:
1. Vacation Donation Program – Unreimbursed Medical Costs (aka Value donation)
2. V
acation Donation Program – Continued Salary (aka Hours donation)
The
maximum amount of vacation leave an employee may donate per fiscal year is 52 hours: 12 hours (or 1 ½ days
personal leave) to the Unreimbursed Medical Costs program, and 40 hours (or 5 days personal leave) to the
Continued Salary program. Donations may be made on-line thru the State Employee Self-Service Web site, or by
submitting this completed form to the agency Human Resources or Payroll offices.
Hou
rs donated in each program may be given to one recipient or may be divided among two or more recipients in that
program.
Once an authorization to donate vacation hours/personal leave days has been processed, it is irrevocable.
Donat
ions must be in whole hour increments, with one hour as the minimum donation.
Vac
ation donations are not considered a charitable contribution for income tax purposes.
If donating hours to the Unreimbursed Medical Costs Program, the monetary value of the employee’s donation will be
included as taxable income to the donor. Therefore, the State will deduct State and Federal Tax at the supplemental
rate, as well as FICA and Medicare, from the monetary value of the hours donated. The amount remaining after these
deductions is the amount transferred to the recipient’s account. This will not change the amount of the donor’s check.
Part One – To be completed by Donating Employee and submitted to agency payroll office
Donat
ing Employee’s Name: ____________________________________________ Employee ID #: ______________
Total number of hours to be deducted from my vacation leave (or personal leave) balance: ______________
I authorize hours to be donated to the following approved Vacation Donation Program recipient(s):
Pr
ogram Recipient Name(s) # of Hours
____________________ _____________________________________________ _________
____________________ _____________________________________________ _________
Signature of Employee: _________________________________________________
Date:
Part Two – To be completed by Payroll Office
I certi
fy that the above named employee has sufficient vacation (or personal leave) balances to cover this contribution.
Signature of Payroll Staff: ________________________________________________
Date:
(Reta
in this form on file with payroll documents for applicable pay period)
PE-00665-03 (7/09)
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