"Catastrophic Leave Bank Program Donation of Leave" - Arkansas

Catastrophic Leave Bank Program Donation of Leave is a legal document that was released by the Arkansas Department of Transformation and Shared Services - a government authority operating within Arkansas.

Form Details:

  • Released on May 27, 2021;
  • The latest edition currently provided by the Arkansas Department of Transformation and Shared Services;
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Department of Transformation and Shared Services
Office of Personnel Management
Catastrophic Leave Bank Program Donation of Leave
Instructions
1. Employee:
Complete and sign Part I and forward to your timekeeper. Accrued leave may be donated in one (1) hour increments only.
Complete and sign Part II and forward to your Human Resources Official.
2. Timekeeper:
3. Human Resources Official: Complete and sign Part III and forward to Department Secretary/Designee for approval.
Sign and return original to HR Official for processing.
4. Director/Designee:
5. Human Resources Official: 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 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 HR Official or Designee
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 HR Official or Designee
Date
Part IV - Department Secretary or Designee Approval
Signature of Department Secretary or Designee
Date
Part V - HR Official or Designee Processes and Submits to OPM
Reviewed and Recorded by OPM - CLB Coordinator or Designee
Signature of CLB Coordinator/Designee
Credit Date for Donated Leave
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
501 Woodlane, Suite 205
Little Rock, AR 72201
OPM Catastrophic Leave Bank Program Donation of Leave (Revised 05/27/2021)
Department of Transformation and Shared Services
Office of Personnel Management
Catastrophic Leave Bank Program Donation of Leave
Instructions
1. Employee:
Complete and sign Part I and forward to your timekeeper. Accrued leave may be donated in one (1) hour increments only.
Complete and sign Part II and forward to your Human Resources Official.
2. Timekeeper:
3. Human Resources Official: Complete and sign Part III and forward to Department Secretary/Designee for approval.
Sign and return original to HR Official for processing.
4. Director/Designee:
5. Human Resources Official: 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 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 HR Official or Designee
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 HR Official or Designee
Date
Part IV - Department Secretary or Designee Approval
Signature of Department Secretary or Designee
Date
Part V - HR Official or Designee Processes and Submits to OPM
Reviewed and Recorded by OPM - CLB Coordinator or Designee
Signature of CLB Coordinator/Designee
Credit Date for Donated Leave
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
501 Woodlane, Suite 205
Little Rock, AR 72201
OPM Catastrophic Leave Bank Program Donation of Leave (Revised 05/27/2021)