CONFIDENTIAL RECORD


Leave Donation Authorization Form

See "lv_donor_guide.htm" at site for general guidelines applicable to employees in all negotiating units

Donor Information

Information About Donor
Name

Title

Salary Grade
Negotiating Unit

 Payroll Item#
 Social Security Number
 Work Phone Number
Work Unit/Location

Recipient Information

Information About Person to Receive Donation
Name

 Work Unit/Location

Donation Information

Number of Vacation Days Donated

Authorization
I hereby authorize the Personnel/Payroll Office to deduct from my vacation balance the number of days indicated above to be used as sick leave by the recipient named above. I certify that the days donated are not days I would otherwise forfeit and that this donation does not cause me to drop below the balance of ten days of vacation as of the date this donation is submitted.

Date

 Signature of Donor

Personnel Services Division
NYS Department of Civil Service
5/96