Form MS401 "State Employees' Leave Bank Enrollment Form" - Maryland

What Is Form MS401?

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 October 1, 2020;
  • 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 MS401 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 MS401 "State Employees' Leave Bank Enrollment Form" - Maryland

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STATE EMPLOYEES’ LEAVE BANK ENROLLMENT FORM
EMPLOYEE TO COMPLETE
(Please TYPE or PRINT)
Please complete this form if you wish to donate leave to JOIN (within first 60 days) or ENROLL/RENEW
(during Open Enrollment) your membership in the State Employees’ Leave Bank.
NAME*: __________________________________ FULL SS#
:__________________________
*
*You must provide your full Name and Social Security Number to help us verify your identity. Failure to do so may
result in rejection of your membership. Your number will be kept confidential in accordance with Federal and State
laws and regulations.
FULL AGENCY NAME: ______________________________ HIRE DATE: _______________
If you are joining the Leave Bank for the FIRST TIME, you must be a member for at least 90 days before you
are eligible to RECEIVE leave.
DONATED
NEW
TYPE OF LEAVE
HOURS
BALANCE
APPLICATION STATUS (√)
Personal
INITIAL – OPEN ENROLLMENT
INITIAL – NEW HIRE (First 60 days)
Annual
**
Sick
RENEWAL – OPEN ENROLLMENT
***
REHIRE
I hereby certify that I agree to donate eight (8) hours of sick, annual or personal leave, or a combination
thereof, to establish membership in the State Employees’ Leave Bank Program. By participating I
understand that I will be a member for two (2) years from the effective date of enrollment.
_______________________________________
________________________
SIGNATURE OF EMPLOYEE
DATE
** New State of Maryland employees are not eligible to donate Annual Leave until they have at least six months
of State Service.
***State of Maryland employees are not eligible to donate Sick Leave unless they will have a balance of at least 240
hours after donation.
APPOINTING AUTHORITY/DESIGNEE TO COMPLETE
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 is subtracted.
Employee’s Membership
____________________________________
_____________
will Expire on:
APPOINTING AUTHORITY/DESIGNEE
DATE
______________________
****************************************
Hrs of selected Leave were deducted from balance on _________ by ___________________/______
Print
/ Initial
(Note: Leave must be adjusted within seven (7) days per COMAR 17.04.11.23)
Original to: Employee File
Copy to:
Employee (Certified)
MS 401 (Rev. 10/2020)
leave.bank@maryland.gov
DBM
STATE EMPLOYEES’ LEAVE BANK ENROLLMENT FORM
EMPLOYEE TO COMPLETE
(Please TYPE or PRINT)
Please complete this form if you wish to donate leave to JOIN (within first 60 days) or ENROLL/RENEW
(during Open Enrollment) your membership in the State Employees’ Leave Bank.
NAME*: __________________________________ FULL SS#
:__________________________
*
*You must provide your full Name and Social Security Number to help us verify your identity. Failure to do so may
result in rejection of your membership. Your number will be kept confidential in accordance with Federal and State
laws and regulations.
FULL AGENCY NAME: ______________________________ HIRE DATE: _______________
If you are joining the Leave Bank for the FIRST TIME, you must be a member for at least 90 days before you
are eligible to RECEIVE leave.
DONATED
NEW
TYPE OF LEAVE
HOURS
BALANCE
APPLICATION STATUS (√)
Personal
INITIAL – OPEN ENROLLMENT
INITIAL – NEW HIRE (First 60 days)
Annual
**
Sick
RENEWAL – OPEN ENROLLMENT
***
REHIRE
I hereby certify that I agree to donate eight (8) hours of sick, annual or personal leave, or a combination
thereof, to establish membership in the State Employees’ Leave Bank Program. By participating I
understand that I will be a member for two (2) years from the effective date of enrollment.
_______________________________________
________________________
SIGNATURE OF EMPLOYEE
DATE
** New State of Maryland employees are not eligible to donate Annual Leave until they have at least six months
of State Service.
***State of Maryland employees are not eligible to donate Sick Leave unless they will have a balance of at least 240
hours after donation.
APPOINTING AUTHORITY/DESIGNEE TO COMPLETE
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 is subtracted.
Employee’s Membership
____________________________________
_____________
will Expire on:
APPOINTING AUTHORITY/DESIGNEE
DATE
______________________
****************************************
Hrs of selected Leave were deducted from balance on _________ by ___________________/______
Print
/ Initial
(Note: Leave must be adjusted within seven (7) days per COMAR 17.04.11.23)
Original to: Employee File
Copy to:
Employee (Certified)
MS 401 (Rev. 10/2020)
leave.bank@maryland.gov
DBM