"Catastrophic Leave Bank Program (Clb) - Donation of Annual and Sick Leave" - Arkansas

Catastrophic Leave Bank Program (Clb) - Donation of Annual and Sick Leave is a legal document that was released by the Arkansas Department of Finance & Administration - a government authority operating within Arkansas.

Form Details:

  • Released on June 15, 2018;
  • The latest edition currently provided by the Arkansas Department of Finance & Administration;
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DEPARTMENT OF FINANCE AND ADMINISTRATION - Office of Personnel Management
(OPM)
Catastrophic Leave Bank Program
- Donation of Annual and Sick Leave
(CLB)
Clear Form
Instructions
1. Employee:
Complete and sign Part I and forward to your timekeeper. Accrued leave may be donated in one (1) hour increments only.
2. Timekeeper:
Complete and sign Part II and forward to your Agency Human Resources Officer.
3. Human Resources Officer: Complete and sign Part III and forward to Agency Director/Designee for approval.
4. Director/Designee:
Sign and return original to Agency Human Resources Officer for processing.
5. Human Resources Officer: Process and submit approved form to OPM.
Part I - Completed By Donor
Personnel #
Name of Donor (Last, First)
Name of Agency
Agency #
Position #
Sick Leave Hours Donated
Total Leave Hours Donated
Annual Leave Hours Donated
Certification of Voluntary Donation
I certify that:
1. I am making this donation entirely of my own free will and that no attempts have been made to intimidate, threaten or coerce me to donate my annual or sick
leave. I understand that I have no right under any circumstances to have any of the donated leave restored to my accrued annual or sick leave totals.
2. I am a regular full-time employee or part-time employee of said agency and I am being compensated on a full-time or part-time basis.
3. This leave time donation will not reduce my combined annual and sick leave balance to less than eight (80) hours (except upon termination or retirement.)
Signature of Donor
Date
Part II - Completed by Donor's Timekeeper
Date of Balance
Annual Leave Balance After Donation
Sick Leave Balance After Donation
Timekeeper's Name
Signature
Phone #
Part III - Completed by Agency Human Resources Officer
Total Leave Hours Donated
Donor's Hourly Rate of Pay
Dollar Value of Donation
Donor's Employment Status
Full-Time
Part-Time
Retirement
Termination
Signature of Authorized Agency Human Resources Officer
Date
Part IV - Approval of Agency Director/Designee
Date
Signature of Authorized Agency Director/Designee
Part V - Agency Human Resources Officer Processes and Submits to OPM
Reviewed and Recorded by OPM - CLB Coordinator or Designee
Credit Date for Donated Leave
Signature of CLB Coordinator/Designee
AASIS Participating Agencies: Key donation and provide form to the OPM Catastrophic Leave Bank.
Service Bureau Agencies: Forward form to OPM for keying donation.
OPM Catastrophic Leave Bank
OPM Catastrophic Leave Bank
1509 West Seventh Street
P.O. Box 3278
DFA Building, Room 201
Little Rock, AR 72203-3278
Little Rock, AR 72201
OPM Catastrophic Leave Bank Program Donation of Annual and Sick Leave (R 6/15/2018)
Print Form
DEPARTMENT OF FINANCE AND ADMINISTRATION - Office of Personnel Management
(OPM)
Catastrophic Leave Bank Program
- Donation of Annual and Sick Leave
(CLB)
Clear Form
Instructions
1. Employee:
Complete and sign Part I and forward to your timekeeper. Accrued leave may be donated in one (1) hour increments only.
2. Timekeeper:
Complete and sign Part II and forward to your Agency Human Resources Officer.
3. Human Resources Officer: Complete and sign Part III and forward to Agency Director/Designee for approval.
4. Director/Designee:
Sign and return original to Agency Human Resources Officer for processing.
5. Human Resources Officer: Process and submit approved form to OPM.
Part I - Completed By Donor
Personnel #
Name of Donor (Last, First)
Name of Agency
Agency #
Position #
Sick Leave Hours Donated
Total Leave Hours Donated
Annual Leave Hours Donated
Certification of Voluntary Donation
I certify that:
1. I am making this donation entirely of my own free will and that no attempts have been made to intimidate, threaten or coerce me to donate my annual or sick
leave. I understand that I have no right under any circumstances to have any of the donated leave restored to my accrued annual or sick leave totals.
2. I am a regular full-time employee or part-time employee of said agency and I am being compensated on a full-time or part-time basis.
3. This leave time donation will not reduce my combined annual and sick leave balance to less than eight (80) hours (except upon termination or retirement.)
Signature of Donor
Date
Part II - Completed by Donor's Timekeeper
Date of Balance
Annual Leave Balance After Donation
Sick Leave Balance After Donation
Timekeeper's Name
Signature
Phone #
Part III - Completed by Agency Human Resources Officer
Total Leave Hours Donated
Donor's Hourly Rate of Pay
Dollar Value of Donation
Donor's Employment Status
Full-Time
Part-Time
Retirement
Termination
Signature of Authorized Agency Human Resources Officer
Date
Part IV - Approval of Agency Director/Designee
Date
Signature of Authorized Agency Director/Designee
Part V - Agency Human Resources Officer Processes and Submits to OPM
Reviewed and Recorded by OPM - CLB Coordinator or Designee
Credit Date for Donated Leave
Signature of CLB Coordinator/Designee
AASIS Participating Agencies: Key donation and provide form to the OPM Catastrophic Leave Bank.
Service Bureau Agencies: Forward form to OPM for keying donation.
OPM Catastrophic Leave Bank
OPM Catastrophic Leave Bank
1509 West Seventh Street
P.O. Box 3278
DFA Building, Room 201
Little Rock, AR 72203-3278
Little Rock, AR 72201
OPM Catastrophic Leave Bank Program Donation of Annual and Sick Leave (R 6/15/2018)