Form ADM4256 "Leave Donation Program - Donor Application Form" - Ohio

What Is Form ADM4256?

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

Form Details:

  • Released on January 1, 2012;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • 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 ADM4256 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4256 "Leave Donation Program - Donor Application Form" - Ohio

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LEAVE DONATION PROGRAM -- DONOR APPLICATION FORM
FOR PAYROLL PERIOD ENDING
: _____________________________
I. DONOR INFORMATION
Donating Employee
:
(Employee ID)
(Last)
(First)
(Middle Initial)
______________________________________________________________________________________________
____________________________________
Department: ________________________________________________________
Division________________________ Employing Unit: ____________________
Number of hours donated
Type of leave donated
Vacation
Sick leave
Personal leave
TOTAL HOURS DONATED (Total must equal a minimum of 8 hours)
II. PERSON TO RECEIVE LEAVE
1. Use of donated leave is limited to 53.6 hours per pay period while awaiting disability benefits.
2. Donated leave may not be used to supplement state-paid benefit program(s) (e.g. disability leave, adoption/childbirth leave or
workers' compensation).
Person to Receive Leave:
(Employee ID)
(Last)
(First)
(Middle Initial)
______________________________________________________________________________________________
____________________________________
Department: ________________________________________________________
Division: ________________________ Employing Unit: ___________________
III. CERTIFICATION
I hereby certify that this request is made voluntarily. I was not coerced, intimidated or financially induced into donating
leave. By signing I hereby relinquish all rights to the leave shown above and the benefits accruing to or attached to the
same. I understand that the donation of leave is irrevocable and irreversible and that no leave will be refunded to me.
I certify that I will have a remaining balance of 80 hours or more of combined leave (sick, vacation, personal and
compensatory) after making this donation.
Date: _____________________
Signature:
______________________________________________
DAS ADM #4256 01/12
LEAVE DONATION PROGRAM -- DONOR APPLICATION FORM
FOR PAYROLL PERIOD ENDING
: _____________________________
I. DONOR INFORMATION
Donating Employee
:
(Employee ID)
(Last)
(First)
(Middle Initial)
______________________________________________________________________________________________
____________________________________
Department: ________________________________________________________
Division________________________ Employing Unit: ____________________
Number of hours donated
Type of leave donated
Vacation
Sick leave
Personal leave
TOTAL HOURS DONATED (Total must equal a minimum of 8 hours)
II. PERSON TO RECEIVE LEAVE
1. Use of donated leave is limited to 53.6 hours per pay period while awaiting disability benefits.
2. Donated leave may not be used to supplement state-paid benefit program(s) (e.g. disability leave, adoption/childbirth leave or
workers' compensation).
Person to Receive Leave:
(Employee ID)
(Last)
(First)
(Middle Initial)
______________________________________________________________________________________________
____________________________________
Department: ________________________________________________________
Division: ________________________ Employing Unit: ___________________
III. CERTIFICATION
I hereby certify that this request is made voluntarily. I was not coerced, intimidated or financially induced into donating
leave. By signing I hereby relinquish all rights to the leave shown above and the benefits accruing to or attached to the
same. I understand that the donation of leave is irrevocable and irreversible and that no leave will be refunded to me.
I certify that I will have a remaining balance of 80 hours or more of combined leave (sick, vacation, personal and
compensatory) after making this donation.
Date: _____________________
Signature:
______________________________________________
DAS ADM #4256 01/12