"Leave Payoff at Separation Request Form" - Ohio

Leave Payoff at Separation Request Form is a legal document that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio.

Form Details:

  • Released on December 1, 2019;
  • The latest edition currently provided by the Ohio Department of Administrative Services;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download "Leave Payoff at Separation Request Form" - Ohio

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STATE OF OHIO
LEAVE PAYOFF AT SEPARATION REQUEST FORM
(for employees paid by warrant of the Director of Budget and Management)
Name: __________________________________
Employee ID: ______________________
Agency: _____________________
Separation Date: __________________________
Bargaining Unit/Exempt
OT Eligible/Exempt
Circle one
Circle one
SICK LEAVE
Sick Leave
I would like to be paid for all of my accumulated sick leave balance.
I would like to be paid for ______ hours of my accumulated sick leave balance with the remainder being held for future payment
(within three (3) years from the date of my separation) or restoration upon re-employment, provided I am re-employed within ten
(10) years of the date of my separation.
I would like to retain all of my accumulated sick leave balance for restoration upon re-employment (provided I am re-employed
within ten (10) years from the date of my separation) or for conversion (provided I convert within three (3) years from the date of
separation.
I would like to transfer my sick leave to __________________________________. Letter from former agency must be attached.
I do not have the service required for sick leave conversion
*Exempts, 1199, Attorney General – require one (1) year of State Service
*OCSEA, FOP, OSTA, OEA, Auditor and Treasurer of State – require five (5) years of State Service
*FOP 46 & 48 upon separation
NOTE: Old sick leave is NOT subject to payoff
VACATION LEAVE
I would like to be paid for all of my accumulated vacation leave balance.
I would like to retain all of my accumulated vacation leave balance for restoration upon re-employment, provided I am re-
employed within thirty (30) days of the date of my separation. I understand that if I am re-employed within thirty (30) days of the
date of my separation, and if I have more vacation leave credit than allowable for my new position, I will receive payment for
excess leave at a rate equal to my base rate of pay for my former position. I understand that if I am not re-employed within thirty
(30) days, my entire vacation leave balance will be paid out.
I do not meet the service requirements for vacation leave conversion.
*Exempts, OCSEA, 1199, FOP2, OSTA1 and OSTA15 – requires completion of 12 months of total service
*OEA – requires completion of one year of service
*Auditor, FOP46 and FOP48 upon separation
PERSONAL LEAVE
I would like to be paid for all of my accumulated personal leave balance.
I would like to retain all of my accumulated personal leave balance for restoration upon re-employment, provided I am re-
employed within thirty (30) days of the date of my separation. I understand that if I am re-employed within thirty (30) days of the
date of my separation, and if I have more personal leave credit than allowable for my new position, I will receive payment for the
excess leave at a rate equal to my base rate of pay for my former position. I understand that if I am not re-employed within thirty
(30) days, my entire personal leave balance will be paid out.
*Exempt employees personal leave will be prorated.
COMPENSATORY TIME
I understand that if I am overtime-eligible, I will be paid for the ___________ hours of compensatory time that I have accrued.
Overtime-exempt employees are not eligible to be paid for the hours of compensatory time they have accrued.
DEFERRED COMPENSATION
I have made arrangements with Deferred Compensation to have $__________________________ from my leave payoff sent to
Deferred Compensation.
______________________________________________
_________________________________________________
Employee Signature
Date
Agency Designee Signature
Date
EMPLOYEE: Please return to your Agency Human Resources Administrator
HR ADMIN: Please fax a copy of the completed form to DAS/HRD Payroll Support at 614-466-1565 or email the form to
DAS.HRD.HCM.PAYROLL@DAS.OHIO.GOV
upon separation of the employee.
12-2019
STATE OF OHIO
LEAVE PAYOFF AT SEPARATION REQUEST FORM
(for employees paid by warrant of the Director of Budget and Management)
Name: __________________________________
Employee ID: ______________________
Agency: _____________________
Separation Date: __________________________
Bargaining Unit/Exempt
OT Eligible/Exempt
Circle one
Circle one
SICK LEAVE
Sick Leave
I would like to be paid for all of my accumulated sick leave balance.
I would like to be paid for ______ hours of my accumulated sick leave balance with the remainder being held for future payment
(within three (3) years from the date of my separation) or restoration upon re-employment, provided I am re-employed within ten
(10) years of the date of my separation.
I would like to retain all of my accumulated sick leave balance for restoration upon re-employment (provided I am re-employed
within ten (10) years from the date of my separation) or for conversion (provided I convert within three (3) years from the date of
separation.
I would like to transfer my sick leave to __________________________________. Letter from former agency must be attached.
I do not have the service required for sick leave conversion
*Exempts, 1199, Attorney General – require one (1) year of State Service
*OCSEA, FOP, OSTA, OEA, Auditor and Treasurer of State – require five (5) years of State Service
*FOP 46 & 48 upon separation
NOTE: Old sick leave is NOT subject to payoff
VACATION LEAVE
I would like to be paid for all of my accumulated vacation leave balance.
I would like to retain all of my accumulated vacation leave balance for restoration upon re-employment, provided I am re-
employed within thirty (30) days of the date of my separation. I understand that if I am re-employed within thirty (30) days of the
date of my separation, and if I have more vacation leave credit than allowable for my new position, I will receive payment for
excess leave at a rate equal to my base rate of pay for my former position. I understand that if I am not re-employed within thirty
(30) days, my entire vacation leave balance will be paid out.
I do not meet the service requirements for vacation leave conversion.
*Exempts, OCSEA, 1199, FOP2, OSTA1 and OSTA15 – requires completion of 12 months of total service
*OEA – requires completion of one year of service
*Auditor, FOP46 and FOP48 upon separation
PERSONAL LEAVE
I would like to be paid for all of my accumulated personal leave balance.
I would like to retain all of my accumulated personal leave balance for restoration upon re-employment, provided I am re-
employed within thirty (30) days of the date of my separation. I understand that if I am re-employed within thirty (30) days of the
date of my separation, and if I have more personal leave credit than allowable for my new position, I will receive payment for the
excess leave at a rate equal to my base rate of pay for my former position. I understand that if I am not re-employed within thirty
(30) days, my entire personal leave balance will be paid out.
*Exempt employees personal leave will be prorated.
COMPENSATORY TIME
I understand that if I am overtime-eligible, I will be paid for the ___________ hours of compensatory time that I have accrued.
Overtime-exempt employees are not eligible to be paid for the hours of compensatory time they have accrued.
DEFERRED COMPENSATION
I have made arrangements with Deferred Compensation to have $__________________________ from my leave payoff sent to
Deferred Compensation.
______________________________________________
_________________________________________________
Employee Signature
Date
Agency Designee Signature
Date
EMPLOYEE: Please return to your Agency Human Resources Administrator
HR ADMIN: Please fax a copy of the completed form to DAS/HRD Payroll Support at 614-466-1565 or email the form to
DAS.HRD.HCM.PAYROLL@DAS.OHIO.GOV
upon separation of the employee.
12-2019