VSL Donation Form

Revised 01/11
DEPARTMENT OF PUBLIC INSTRUCTION
VOLUNTARY SHARED LEAVE DONATION FORM
DATE:
DONOR NAME (please print name):
SIGNATURE: ________________________________________________
(Please read all the information on this form before signing)
DIVISION/SECTION: ___________________________________________
Please donate _________hours from my vacation or bonus leave account (specify
vacation or bonus) to __________________________. (Employee approved for
VSL)
Please donate _________hours from my sick leave account to
_____________________________. (Employee approved for VSL)
Relationship to the recipient: ______________________________.
If donating to an employee in an agency other than DPI, please list the agency’s
name ________________________.
NOTE: The minimum amount of leave that may be donated is four hours. Leave
donated can be vacation, sick, or bonus leave by family and non-family members.
Non-family member sick donations can not be more than 5 days per year to any one
non-family member recipient. The maximum amount of vacation leave that may be
donated may not be more than the amount of the donor’s annual accrual rate and
may not reduce the donor’s vacation leave balance below one-half of the annual
vacation leave accrual rate. The maximum amount of sick leave that may be
donated is 1040 hours, but may not reduce the donor’s sick leave balance below 40
hours. Bonus leave may be donated without regard to the above limitations on
vacation or sick leave.
ADVISORY: Donating sick leave can adversely affect your retirement benefit.
FOR HUMAN RESOURCES DIVISION USE ONLY
HRD APPROVAL SIGNATURE/DATE : __________________________________
HRD COMMENTS : ____________________________________________________
_______________________________________________________________________
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