Www.dms.myflorida.com



-113474529972000-14287563500PART I – DONOR AND RECIPENT INFORMATIONPART I – DONOR AND RECIPENT INFORMATIONDonor InformationRecipient InformationEmployee Name Employee People First ID # State Personnel System Agency 6953261371600Number of Sick leave Hours I Request to Donate: _______________00Number of Sick leave Hours I Request to Donate: _______________-2705101586865? I certify that I am eligible to donate leave based on the applicable requirements and provisions of subsection 60L-34.0042(5), Florida Administrative Code.00? I certify that I am eligible to donate leave based on the applicable requirements and provisions of subsection 60L-34.0042(5), Florida Administrative Code.-224790237300? I understand that the donated sick leave credits will be permanently deducted from my sick leave balances but if unused, will be returned.00? I understand that the donated sick leave credits will be permanently deducted from my sick leave balances but if unused, will be returned.-219075132715Are you related to the recipient by birth, marriage, or other legal relationship as specified in paragraph 60L-34.0042(5)(b), F.A.C. (spouse, parents, grandparents, brothers, sisters, children, grandchildren of either the employee or spouse)?? Yes or ? No If yes, describe the relationship: ______________00Are you related to the recipient by birth, marriage, or other legal relationship as specified in paragraph 60L-34.0042(5)(b), F.A.C. (spouse, parents, grandparents, brothers, sisters, children, grandchildren of either the employee or spouse)?? Yes or ? No If yes, describe the relationship: ______________3755390234315Date: _______________________00Date: _______________________-189865238570Donor Signature: _______________________________________00Donor Signature: _______________________________________-193675171895Return this form to your Human Resources (HR) office for processing. For questions or assistance with this form please contact your HR representative. 00Return this form to your Human Resources (HR) office for processing. For questions or assistance with this form please contact your HR representative. -142240311340For HR Office Use Only:PART II – RECORD OF LEAVE CREDITS PROCESSED00For HR Office Use Only:PART II – RECORD OF LEAVE CREDITS PROCESSED-203200225870Donor’s Agency: ________________________________________ ? Approved or ? Denied00Donor’s Agency: ________________________________________ ? Approved or ? Denied690880348425Hours Charged: ______________ Sick leave ______________ Pay Period: ______________00Hours Charged: ______________ Sick leave ______________ Pay Period: ______________-219075123190HR Representative (Print Name): _________________________________00HR Representative (Print Name): _________________________________4003675121095Date: _______________________00Date: _______________________center187458-197790235585Recipient’s Agency: ________________________________________ ? Approved or ? Denied00Recipient’s Agency: ________________________________________ ? Approved or ? Denied-245110245415? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Annual or ? Sick Leave Hours Credited: ______________ Pay Period: ______________? Annual or ? Sick Leave Hours Credited: ______________ Pay Period: ______________00? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Sick Leave Hours Credited: ______________ Pay Period: ______________? Annual or ? Sick Leave Hours Credited: ______________ Pay Period: ______________? Annual or ? Sick Leave Hours Credited: ______________ Pay Period: ______________3997960354965Date: _______________________00Date: _______________________-226060357810HR Representative (Print Name): _________________________________00HR Representative (Print Name): _________________________________center292735PART III – RETURN OF UNUSED LEAVE CREDITS (if applicable)PART III – RETURN OF UNUSED LEAVE CREDITS (if applicable)FromToEmployee NameEmployee People First ID #State Personnel System AgencyHR Representative-525432555875Email or Mail Address Returned To: ________________________________________________________00Email or Mail Address Returned To: ________________________________________________________-125464287452900-226060184747Number of Sick leave Hours Returned: ______________Date Returned: _______________________00Number of Sick leave Hours Returned: ______________Date Returned: _______________________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download