"Leave Recipient Request Form" - South Carolina

Leave Recipient Request Form is a legal document that was released by the South Carolina Military Department - a government authority operating within South Carolina.

Form Details:

  • Released on March 31, 2017;
  • The latest edition currently provided by the South Carolina Military Department;
  • 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 fillable version of the form by clicking the link below or browse more documents and templates provided by the South Carolina Military Department.

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State Human Resources Policy #E24-104
OFFICE OF THE ADJUTANT GENERAL
LEAVE RECIPIENT REQUEST FORM
Name: __________________________
SCEIS Personnel Number: ___________________
Employing Agency: Office of the Adjutant General
Employment Date: __________
Sick Leave used for current personal emergency: _______ hours
Annual Leave used for personal emergency: _______ hours
Date all paid leave was/will be exhausted: __________
1st day of Leave without Pay: __________
*Inclusive Dates of Personal Emergency: From: __________
To: __________
Inclusive Dates of Leave Request: From: __________
To: __________
Leave request, minus holidays, equals 30 workdays: Yes
No
No
Are you receiving other paid leave benefits for which you are eligible? Yes
If yes, which of the following:
Workers’ Compensation
Eligibility date __________
Long-Term Disability
Eligibility date __________
Other
Eligibility date __________
______________________________
__________
Signature of Leave Recipient
Date
______________________________
__________
Signature of Approver
Date
*Attach statement describing catastrophic or medical emergency of prolonged period without pay.
Attach physician verification.
Revised: 31 March 2017
State Human Resources Policy #E24-104
OFFICE OF THE ADJUTANT GENERAL
LEAVE RECIPIENT REQUEST FORM
Name: __________________________
SCEIS Personnel Number: ___________________
Employing Agency: Office of the Adjutant General
Employment Date: __________
Sick Leave used for current personal emergency: _______ hours
Annual Leave used for personal emergency: _______ hours
Date all paid leave was/will be exhausted: __________
1st day of Leave without Pay: __________
*Inclusive Dates of Personal Emergency: From: __________
To: __________
Inclusive Dates of Leave Request: From: __________
To: __________
Leave request, minus holidays, equals 30 workdays: Yes
No
No
Are you receiving other paid leave benefits for which you are eligible? Yes
If yes, which of the following:
Workers’ Compensation
Eligibility date __________
Long-Term Disability
Eligibility date __________
Other
Eligibility date __________
______________________________
__________
Signature of Leave Recipient
Date
______________________________
__________
Signature of Approver
Date
*Attach statement describing catastrophic or medical emergency of prolonged period without pay.
Attach physician verification.
Revised: 31 March 2017