Form MS405 "Request Form - Employee-To-Employee Leave Donation Program" - Maryland

What Is Form MS405?

This is a legal form that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Maryland Department of Budget and Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MS405 by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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Download Form MS405 "Request Form - Employee-To-Employee Leave Donation Program" - Maryland

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EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
PART I - TO BE COMPLETED BY
DONATING EMPLOYEE
(Please TYPE or PRINT with black or blue Ink)
Name of Donating Employee*:
W# of Donating Employee*:
State Hire Date:
* Your full Name and Workday Number (W#) are required to help verify your identity. Failure to provide it may result in delays and/or rejection of this
request. This information is kept confidential.
Donating Employee’s Agency Name:
Agency Division:
RECEIVING EMPLOYEE’S INFORMATION:
Name of Employee:
Employee’s Agency Name:
Employee’s W#:
LEAVE BALANCE AFTER
TYPE OF LEAVE DONATED:
TOTAL HOURS DONATED:
DONATION:
SICK**
ANNUAL
PERSONAL
I understand that if the employee to whom I am donating leave does not use the leave for any reason, the unused
donated leave shall be returned to my leave balances by my Appointing Authority.
Signature:
Date:
** If you are donating sick leave, you must maintain a balance of at least 240 hours of sick leave after
the donation is deducted.
CERTIFICATION OF LEAVE FOR DONATING EMPLOYEE –
TO BE COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
ANNUAL/PERSONAL LEAVE CERTIFICATION: I have reviewed this employee’s leave balances and affirm
that s/he has sufficient annual/personal leave to make this donation.
SICK LEAVE CERTIFICATION: I have reviewed this employee’s sick leave balance. I affirm that s/he will
have a sick leave balance of at least 240 hours after this donation. As the Appointing Authority/Designee for
the employee making the above leave donation, I certify this donation is in compliance with COMAR
17.04.11.22 C (3).
_______________________________________________
_________________________
APPOINTING AUTHORITY/DESIGNEE
DATE
(Per COMAR 17.04.11.22 C (11) The appointing authority of an employee who donates leave shall adjust the
donating employee’s leave balance before forwarding a copy of the MS 405 form to the receiving employee’s
appointing authority. If the receiving employee is denied the use of donated leave, the receiving employee’s
appointing authority shall notify the donating employee’s appointing authority within 7 days of the denial, and the
donating employee’s appointing authority shall restore the leave balance of the donating employee within 14 days
of notification from the receiving employee’s appointing authority.)
MS 405
Page 1 of 2
(Rev.7/2021)
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
PART I - TO BE COMPLETED BY
DONATING EMPLOYEE
(Please TYPE or PRINT with black or blue Ink)
Name of Donating Employee*:
W# of Donating Employee*:
State Hire Date:
* Your full Name and Workday Number (W#) are required to help verify your identity. Failure to provide it may result in delays and/or rejection of this
request. This information is kept confidential.
Donating Employee’s Agency Name:
Agency Division:
RECEIVING EMPLOYEE’S INFORMATION:
Name of Employee:
Employee’s Agency Name:
Employee’s W#:
LEAVE BALANCE AFTER
TYPE OF LEAVE DONATED:
TOTAL HOURS DONATED:
DONATION:
SICK**
ANNUAL
PERSONAL
I understand that if the employee to whom I am donating leave does not use the leave for any reason, the unused
donated leave shall be returned to my leave balances by my Appointing Authority.
Signature:
Date:
** If you are donating sick leave, you must maintain a balance of at least 240 hours of sick leave after
the donation is deducted.
CERTIFICATION OF LEAVE FOR DONATING EMPLOYEE –
TO BE COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
ANNUAL/PERSONAL LEAVE CERTIFICATION: I have reviewed this employee’s leave balances and affirm
that s/he has sufficient annual/personal leave to make this donation.
SICK LEAVE CERTIFICATION: I have reviewed this employee’s sick leave balance. I affirm that s/he will
have a sick leave balance of at least 240 hours after this donation. As the Appointing Authority/Designee for
the employee making the above leave donation, I certify this donation is in compliance with COMAR
17.04.11.22 C (3).
_______________________________________________
_________________________
APPOINTING AUTHORITY/DESIGNEE
DATE
(Per COMAR 17.04.11.22 C (11) The appointing authority of an employee who donates leave shall adjust the
donating employee’s leave balance before forwarding a copy of the MS 405 form to the receiving employee’s
appointing authority. If the receiving employee is denied the use of donated leave, the receiving employee’s
appointing authority shall notify the donating employee’s appointing authority within 7 days of the denial, and the
donating employee’s appointing authority shall restore the leave balance of the donating employee within 14 days
of notification from the receiving employee’s appointing authority.)
MS 405
Page 1 of 2
(Rev.7/2021)
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
PART II - TO BE COMPLETED BY EMPLOYEE RECEIVING LEAVE DONATIONS
(
Please TYPE or PRINT with Black or Blue ink)
Name*:
W#*:
* Your full Name and Workday Number (W#) are required to help verify your identity and process your Request. Failure to provide it may result in delays
and/or rejection of your request. This information is kept confidential.
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Request Type:
New
Extension
Agency Name:
Reason for Request:
An illness or disability of the employee due to a serious and prolonged medical condition that existed at the time
or
the leave was donated;
A catastrophic illness or injury of a member of the employee's immediate family for whom the employee is
needed to provide direct care**.
**For family member please provide - Name:
Relationship:
**Describe care to be provided:
Signature:
Date:
TO BE COMPLETED BY AGENCY LEAVE BANK/DONATION COORDINATOR
Leave Bank/Donation Coordinator:
Email:
Phone #:
Fax #:
Employee Hire Date:
Last Day Employee Worked: ___________
Dates to Cover: From: ___________ Through: ___________
Donations Received: _________ Hrs
Hours Needed: __________ Hrs
If Yes, provide end date of current FMLA:
Is employee on FMLA leave? No
Yes
Has the employee been seen by the State Medical Director? No
Yes
If Yes, provide copy of SMD Report
Leave Coordinator’s Signature:
Date:
COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
As the Appointing Authority/Designee for the employee receiving the leave donation, I certify that this employee has
exhausted all forms of annual, sick, personal and compensatory time because of a serious and prolonged medical condition.
Approval will not cause the employee to exceed 2,080 hours of leave from the Leave Bank and/or Employee-to-Employee Leave
Donation Programs during his/her entire State employment. Approval will not cause the employee to exceed 16 months of
continuous leave, when combined with all other forms of paid leave. As the appointing authority or designee for this employee, I
have reviewed the employee’s records and I certify that this request meets all of the criteria specified in this Section.
______________________________________________________________
______________________________________
Signature of Appointing Authority or Designee
Date
Page 2 of 2
MS 405
(Rev. 7/2021)
Page of 2