Form TS-12 "Voluntary Leave Without Pay" - Nevada

What Is Form TS-12?

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

Form Details:

  • Released on February 1, 2013;
  • The latest edition provided by the Nevada Department of Administration;
  • 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 printable version of Form TS-12 by clicking the link below or browse more documents and templates provided by the Nevada Department of Administration.

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Download Form TS-12 "Voluntary Leave Without Pay" - Nevada

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State of Nevada
VOLUNTARY LEAVE WITHOUT PAY
Authorized pursuant to NAC 284.580
In response to the shortfall in revenues or fiscal emergency declared by the Governor,
I,
, am requesting a Voluntary Leave Without Pay (UVLWP) on the
print name
following date(s) and for the number of hours specified:
DATE(S)
HOURS PER DAY*
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
*
NOTE: Exempt employees do not need to list the hours per day.
An
appointing authority shall not approve UVLWP that consists of any partial
working days for exempt employees. An exempt employee is defined in
NRS 284.148.
The time designated for UVLWP is subject to mutual agreement by me and my appointing authority. I
understand this agreement provides for the continuation of benefits provided by Chapter 284 of the
Nevada Administrative Code. I understand that my group insurance will be affected if I have less than 80
hours of paid work and paid leave in a calendar month. I understand my service credit for retirement will
be reduced and it could also reduce my retirement benefit.
Further, I understand that this mutual agreement will terminate when the shortfall in revenues or fiscal
emergency ends and can be terminated by the employer or myself at any time.
____________________________________________________________________________________
Employee Signature
Date
Approved
Disapproved
____________________________________________________________________________________
Appointing Authority Signature
Date
Distribution: Original to Agency Personnel Office, one copy to Agency Payroll Office and one copy to
DHRM Central Payroll
Rev. 2/13
Voluntary Leave without Pay (TS-12)
Page 1 of 1
State of Nevada
VOLUNTARY LEAVE WITHOUT PAY
Authorized pursuant to NAC 284.580
In response to the shortfall in revenues or fiscal emergency declared by the Governor,
I,
, am requesting a Voluntary Leave Without Pay (UVLWP) on the
print name
following date(s) and for the number of hours specified:
DATE(S)
HOURS PER DAY*
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
*
NOTE: Exempt employees do not need to list the hours per day.
An
appointing authority shall not approve UVLWP that consists of any partial
working days for exempt employees. An exempt employee is defined in
NRS 284.148.
The time designated for UVLWP is subject to mutual agreement by me and my appointing authority. I
understand this agreement provides for the continuation of benefits provided by Chapter 284 of the
Nevada Administrative Code. I understand that my group insurance will be affected if I have less than 80
hours of paid work and paid leave in a calendar month. I understand my service credit for retirement will
be reduced and it could also reduce my retirement benefit.
Further, I understand that this mutual agreement will terminate when the shortfall in revenues or fiscal
emergency ends and can be terminated by the employer or myself at any time.
____________________________________________________________________________________
Employee Signature
Date
Approved
Disapproved
____________________________________________________________________________________
Appointing Authority Signature
Date
Distribution: Original to Agency Personnel Office, one copy to Agency Payroll Office and one copy to
DHRM Central Payroll
Rev. 2/13
Voluntary Leave without Pay (TS-12)
Page 1 of 1