"Catastrophic Sick Leave Transfer Authorization Form" - Alabama

Catastrophic Sick Leave Transfer Authorization Form is a legal document that was released by the Alabama Department of Youth Services - a government authority operating within Alabama.

Form Details:

  • Released on August 1, 2011;
  • The latest edition currently provided by the Alabama Department of Youth Services;
  • Ready to use and print;
  • Easy to customize;
  • 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 Alabama Department of Youth Services.

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Download "Catastrophic Sick Leave Transfer Authorization Form" - Alabama

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Revised August 2011
Alabama
Department of Youth Services School District
#210
Sick Leave Bank Participant
Catastrophic Sick Leave Transfer Authorization
Please Print
Donating Employee Information
To be completed by donating employee
1. Employee Name:
2. Social Security Number:
3. Employee Address:
4. Employee Telephone(s):
5. Employer:
Bene ciary Employee Information
-
To be completed by donating employee
6. Receiving Employee Name:
7. Social Security Number:
8. Bene ciary’s Employer:
Days to be donated to Bene ciary (
)
not to exceed 30 days
per any employee
To be completed by donating employee
9. Number of Days to be donated:
Certi cation of Donating Employee
– To be completed by donating employee
10. I certify that I hereby donate the above noted number of my sick leave days to the beneficiary employee
listed above. My employer has my permission to transfer the indicated number of sick leave days to the
employer of the beneficiary for his or her use to a catastrophic illness/injury as defined by Act 93-753. It is my
understanding that my sick leave balance will be reduced by the specified number of days hereon and that the
donated days will not be returned to me.
Donating employee’s signature:__________________________ ______________ Date: ______________________
Witness’ signature: ___________________________________________________ Date: ______________________
Certi cation of Donating Employer
– To be completed by donating employee
11. I hereby certify that the donating employee’s information listed above is correct to the best of my knowledge.
Authorizing Signature: ___________________________________________________Date: ___________________
Title: _____________________________________________________
Receipt of Bene ciary Employer
– To be completed by Bene ciary’s employer
12. The above noted number of sick leave days have been credited to the sick leave account of the beneficiary
employee. (Please give a copy of this from to the beneficiary employee.)
Authorizing Signature: ______________________________________________ Date: _____________________
Title: __________________________________________________________________
Revised August 2011
Alabama
Department of Youth Services School District
#210
Sick Leave Bank Participant
Catastrophic Sick Leave Transfer Authorization
Please Print
Donating Employee Information
To be completed by donating employee
1. Employee Name:
2. Social Security Number:
3. Employee Address:
4. Employee Telephone(s):
5. Employer:
Bene ciary Employee Information
-
To be completed by donating employee
6. Receiving Employee Name:
7. Social Security Number:
8. Bene ciary’s Employer:
Days to be donated to Bene ciary (
)
not to exceed 30 days
per any employee
To be completed by donating employee
9. Number of Days to be donated:
Certi cation of Donating Employee
– To be completed by donating employee
10. I certify that I hereby donate the above noted number of my sick leave days to the beneficiary employee
listed above. My employer has my permission to transfer the indicated number of sick leave days to the
employer of the beneficiary for his or her use to a catastrophic illness/injury as defined by Act 93-753. It is my
understanding that my sick leave balance will be reduced by the specified number of days hereon and that the
donated days will not be returned to me.
Donating employee’s signature:__________________________ ______________ Date: ______________________
Witness’ signature: ___________________________________________________ Date: ______________________
Certi cation of Donating Employer
– To be completed by donating employee
11. I hereby certify that the donating employee’s information listed above is correct to the best of my knowledge.
Authorizing Signature: ___________________________________________________Date: ___________________
Title: _____________________________________________________
Receipt of Bene ciary Employer
– To be completed by Bene ciary’s employer
12. The above noted number of sick leave days have been credited to the sick leave account of the beneficiary
employee. (Please give a copy of this from to the beneficiary employee.)
Authorizing Signature: ______________________________________________ Date: _____________________
Title: __________________________________________________________________