Form PER1095 "Confidential Donation of Accrued Paid Leave to Employee - Catastrophic Illness/Injury Timebank" - County of Santa Cruz, California

What Is Form PER1095?

This is a legal form that was released by the Personnel Department - County of Santa Cruz, California - a government authority operating within California. The form may be used strictly within County of Santa Cruz. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 23, 2015;
  • The latest edition provided by the Personnel Department - County of Santa Cruz, California;
  • 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 fillable version of Form PER1095 by clicking the link below or browse more documents and templates provided by the Personnel Department - County of Santa Cruz, California.

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Download Form PER1095 "Confidential Donation of Accrued Paid Leave to Employee - Catastrophic Illness/Injury Timebank" - County of Santa Cruz, California

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TO: COUNTY PERSONNEL DEPARTMENT
ATTENTION: Personnel - Time Bank Program
CONFIDENTIAL
DONATION OF ACCRUED PAID LEAVE TO EMPLOYEE-CATASTROPHIC
ILLNESS/INJURY TIMEBANK
I understand that this donation of leave hours is irrevocable and, should the person
receiving the donation not use all donated time for the catastrophic illness/injury, any
balance will remain with that person.
I understand that I may only donate the following types of accrued leave: vacation,
administrative leave. (Sick leave and accrued compensatory time may not be donated.)
I understand that I may donate leave in increments of 4 hours or more and that I cannot
donate leave which would reduce my total accrued leave balance (for vacation,
compensatory time, administrative leave, sick leave) to less than 168 hours.
I have read and understand all of the above, and I freely and without restraint elect to
donate
hours of
to a Time Bank established for the
benefit of
Employee #
_.
Employee's Name (Print)
_Employee #
Signature
_Date
P LEASE INITIAL THIS BOX IF YOU ARE AT THE MAXIMUM ACCRUAL LEVEL OF
VACATION, ANNUAL LEAVE, ADMINISTRATIVE LEAVE, OR ARE IN DANGER OF
"LOSING" THESE HOURS, AND WOULD LIKE YOUR DONATION TO TAKE EFFECT
THE SAME PAY PERIOD (DEADLINES PERMITTING) THAT PERSONNEL RECEIVES
IT.
PER1095 7/28/98 Rev., for Intranet use 05/23/07, Rev. 10/5/10, Rev. 11/23/15
TO: COUNTY PERSONNEL DEPARTMENT
ATTENTION: Personnel - Time Bank Program
CONFIDENTIAL
DONATION OF ACCRUED PAID LEAVE TO EMPLOYEE-CATASTROPHIC
ILLNESS/INJURY TIMEBANK
I understand that this donation of leave hours is irrevocable and, should the person
receiving the donation not use all donated time for the catastrophic illness/injury, any
balance will remain with that person.
I understand that I may only donate the following types of accrued leave: vacation,
administrative leave. (Sick leave and accrued compensatory time may not be donated.)
I understand that I may donate leave in increments of 4 hours or more and that I cannot
donate leave which would reduce my total accrued leave balance (for vacation,
compensatory time, administrative leave, sick leave) to less than 168 hours.
I have read and understand all of the above, and I freely and without restraint elect to
donate
hours of
to a Time Bank established for the
benefit of
Employee #
_.
Employee's Name (Print)
_Employee #
Signature
_Date
P LEASE INITIAL THIS BOX IF YOU ARE AT THE MAXIMUM ACCRUAL LEVEL OF
VACATION, ANNUAL LEAVE, ADMINISTRATIVE LEAVE, OR ARE IN DANGER OF
"LOSING" THESE HOURS, AND WOULD LIKE YOUR DONATION TO TAKE EFFECT
THE SAME PAY PERIOD (DEADLINES PERMITTING) THAT PERSONNEL RECEIVES
IT.
PER1095 7/28/98 Rev., for Intranet use 05/23/07, Rev. 10/5/10, Rev. 11/23/15