State Form 49044 "Request for Leave and Verification of Services Provided - State Employee Community Service Program" - Indiana

What Is State Form 49044?

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

Form Details:

  • Released on April 1, 1999;
  • The latest edition provided by the Indiana State Department of Personnel;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of State Form 49044 by clicking the link below or browse more documents and templates provided by the Indiana State Department of Personnel.

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Download State Form 49044 "Request for Leave and Verification of Services Provided - State Employee Community Service Program" - Indiana

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STATE EMPLOYEE COMMUNITY SERVICE PROGRAM
REQUEST FOR LEAVE AND VERIFICATION OF SERVICES PROVIDED
State Form 49044 (R / 4-99)
PART 1 - REQUEST FOR LEAVE
To be filled out by employee:
I, ______________________________________________________________ , request leave in accordance with Executive Order 98-13 to participate in
(Name of employee)
__________________________________________________________________________________________________________________________
(Name of program)
on ___________________________________ from ____________________ to ____________________ .
(Date)
(Time)
(Time)
Printed name of employee
Signature of employee
Date (month, day, year)
PART 2 - VERIFICATION OF PRIOR VOLUNTARY SERVICE
To be filled out by authorized representative of a governmental entity or tax exempt organization:
I am an authorized representative of ____________________________________________________________________________________________
(Name of organization)
which is a governmental entity or is exempt from federal income tax. I verify that the above named individual performed _________________ hours of
voluntary service on behalf of the organization on __________________________ .
[Date(s)]
Signature of Authorized Representative
Printed name of Authorized Representative
Title
Telephone number
PART 3 - EMPLOYING AGENCY'S RESPONSE TO LEAVE REQUEST
To be filled out by agency head's designee:
The above request for leave is:
Approved
Disapproved
If disapproved, reason:
Date (month, day, year)
Signature of Agency Head's Designee
PART 4 - VERIFICATION OF VOLUNTARY SERVICES PERFORMED DURING NORMAL HOURS OF EMPLOYMENT
To be filled out by an authorized representative of a governmental entity or an organization that is exempt from federal income tax under
Section 501(c) (3) of the Internal Revenue Code:
I verify that voluntary services were performed by the above name state employee on behalf of ___________________________________________
(Name of organization)
on _______________________________ from ____________________ to ____________________. I confirm that the volunteer activities did not promote
(Time)
(Time)
(Date)
religion or attempt to influence legislation, governmental policy, or election to public office.
Signature of Authorized Representative
Printed name of Authorized Representative
Title
Telephone number
STATE EMPLOYEE COMMUNITY SERVICE PROGRAM
REQUEST FOR LEAVE AND VERIFICATION OF SERVICES PROVIDED
State Form 49044 (R / 4-99)
PART 1 - REQUEST FOR LEAVE
To be filled out by employee:
I, ______________________________________________________________ , request leave in accordance with Executive Order 98-13 to participate in
(Name of employee)
__________________________________________________________________________________________________________________________
(Name of program)
on ___________________________________ from ____________________ to ____________________ .
(Date)
(Time)
(Time)
Printed name of employee
Signature of employee
Date (month, day, year)
PART 2 - VERIFICATION OF PRIOR VOLUNTARY SERVICE
To be filled out by authorized representative of a governmental entity or tax exempt organization:
I am an authorized representative of ____________________________________________________________________________________________
(Name of organization)
which is a governmental entity or is exempt from federal income tax. I verify that the above named individual performed _________________ hours of
voluntary service on behalf of the organization on __________________________ .
[Date(s)]
Signature of Authorized Representative
Printed name of Authorized Representative
Title
Telephone number
PART 3 - EMPLOYING AGENCY'S RESPONSE TO LEAVE REQUEST
To be filled out by agency head's designee:
The above request for leave is:
Approved
Disapproved
If disapproved, reason:
Date (month, day, year)
Signature of Agency Head's Designee
PART 4 - VERIFICATION OF VOLUNTARY SERVICES PERFORMED DURING NORMAL HOURS OF EMPLOYMENT
To be filled out by an authorized representative of a governmental entity or an organization that is exempt from federal income tax under
Section 501(c) (3) of the Internal Revenue Code:
I verify that voluntary services were performed by the above name state employee on behalf of ___________________________________________
(Name of organization)
on _______________________________ from ____________________ to ____________________. I confirm that the volunteer activities did not promote
(Time)
(Time)
(Date)
religion or attempt to influence legislation, governmental policy, or election to public office.
Signature of Authorized Representative
Printed name of Authorized Representative
Title
Telephone number
COMMUNITY SERVICE LEAVE
PURPOSE:
To promote the direct involvement of state
employees in public services in their communities
through volunteer efforts.
SCOPE:
This policy applies to employees subject to the
jurisdiction of the State Personnel Department or
employed by the State Police Department.
Each full time State employee will be allowed leave
STATEMENT OF POLICY:
with pay from the employee's regular assigned
duties, not to exceed a combined total of seven
and one-half hours (7.5) each calendar year
(including the remainder of calendar year 1998),
to voluntarily participate in activities for the benefit
of another governmental entity or an organization
that is exempt from federal income taxation under
Section 501(c)(3) of the Internal Revenue Code.
The voluntary activities must not promote religion
or attempt to influence legislation, governmental
policy, or elections to public office.
RESPONSIBILITY:
It shall be the responsibility of the employee to
request such leave at least seven (7) calendar
days in advance, unless the request is to provide
services in emergency situations, and in writing
on the prescribed form. (Attached)
To be eligible for leave with pay under this program,
the employee must provide written documentation
on the prescribed form, that, prior to the date(s)
for which the employee has requested this leave,
the employee has donated an equivalent amount
of the employee's own time to a governmental
entity or tax-exempt organization.
It shall be the responsibility of the agency head or
his/her designee to provide a written response to
the employee on the prescribed form approving
or disapproving each request for leave. If
disapproved, the reason must be stated on the
form. Such notification shall be provided prior to
the date(s) for which leave is requested.
Executive Order 98-13
REFERENCES:
July 1, 1998
EFFECTIVE DATE:
APPROVAL:
D. Sue Roberson
State Personnel Director
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