"Donor's Vacation Transfer Form for Employees With a Catastrophically Ill Family Member" - City and County of San Francisco, California

Donor's Vacation Transfer Form for Employees With a Catastrophically Ill Family Member is a legal document that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco.

Form Details:

  • The latest edition currently provided by the Department of Human Resources - City and County of San Francisco, California;
  • 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 Department of Human Resources - City and County of San Francisco, California.

ADVERTISEMENT
ADVERTISEMENT

Download "Donor's Vacation Transfer Form for Employees With a Catastrophically Ill Family Member" - City and County of San Francisco, California

Download PDF

Fill PDF online

Rate (4.5 / 5) 78 votes
City and County of San Francisco
Office of the Controller
Payroll/Personnel Services Division
T.J. ANTHONY CATASTROPHIC ILLNESS PROGRAM FAMILY MEMBER
(CIP-FM)
Donor's Vacation Transfer Form for Employees with a Catastrophically Ill
Family Member
Donor must not be catastrophically ill
CAT ILL PPE __________________________ REC. I.D. #
___________________________
Donor Conditions:
Transfers must be in units of 8 hours
Once transferred, all donations are irrevocable
Transfer Conditions:
A maximum of 80 hours per pay period, and 480
Leave credits may be transferred to the CIP-FM
hours per fiscal year may be transferred
individual recipient or CIP-FM pool once per pay period
Marital status declaration of spousal consent must
Donations are subject to the San Francisco
be completed below
Administrative Code, Section 16.9-29B
I have read and understand the above conditions. I declare under penalty of perjury that I have not and will not
solicit or accept any compensation, directly or indirectly, for the leave hours I am transferring. I further declare that
I am transferring the leave hours of my own free will and not under threat or coercion by any individual.
I choose to transfer
hours of VACATION CREDITS to CIP-FM:
Donor’s Name (please print): __________________________________________________________________ DSW#: ____________________
or
CIP-FM pool
Individual Recipient Identification Number (RIN):
City Department: _______________________________________________________________________ 3-letter Dept. Code: _______________
Donor’s Signature: _____________________________________________________________________ Date: ________________________________
I, ___________________________________________________________________________, declare under penalty of perjury that: (check one)
Marital Status Declaration:
PRINT NAME
I am not married
I do not know, and have taken all reasonable steps to determine, the whereabouts of my current spouse
My current spouse and I have executed a marriage settlement agreement pursuant to Title II of Part 5 of Division 4
of the California Civil Code (or a predecessor statute, if applicable) which makes my earnings my separate property.
Donor’s Signature: ___________________________________________________________________________ Date: ______________________________
I, ______________________________________________________________________, declare under penalty of perjury that I am the legal
Or Spousal Consent:
PRINT NAME
spouse of _________________________________________________________, and I have been informed of my spouse's transfer of
DONOR’S NAME
vacation credits as an irrevocable donation to a City employee designated as having a catastrophically ill family
member, and I hereby consent to this transfer by my spouse.
Spouse’s Signature: __________________________________________________________________________ Date: ______________________________
TO ENSURE CONFIDENTIALITY, send the original directly to the attention of payroll:
San Francisco Unified School District
Office of the Controller
SFUSD EMPLOYEES ONLY:
ALL OTHER CITY EMPLOYEES:
135 Van Ness Ave. Rm. 101, SF, CA 94102-5207
Payroll/Personnel Services Division
One South Van Ness Ave. 8
Floor, SF, CA 94103
th
S.F. Community College
OR
33 Gough St., SF, CA 94102-1214
DONOR: keep a copy of this form for your files, and provide a copy to your department payroll supervisor.
City and County of San Francisco
Office of the Controller
Payroll/Personnel Services Division
T.J. ANTHONY CATASTROPHIC ILLNESS PROGRAM FAMILY MEMBER
(CIP-FM)
Donor's Vacation Transfer Form for Employees with a Catastrophically Ill
Family Member
Donor must not be catastrophically ill
CAT ILL PPE __________________________ REC. I.D. #
___________________________
Donor Conditions:
Transfers must be in units of 8 hours
Once transferred, all donations are irrevocable
Transfer Conditions:
A maximum of 80 hours per pay period, and 480
Leave credits may be transferred to the CIP-FM
hours per fiscal year may be transferred
individual recipient or CIP-FM pool once per pay period
Marital status declaration of spousal consent must
Donations are subject to the San Francisco
be completed below
Administrative Code, Section 16.9-29B
I have read and understand the above conditions. I declare under penalty of perjury that I have not and will not
solicit or accept any compensation, directly or indirectly, for the leave hours I am transferring. I further declare that
I am transferring the leave hours of my own free will and not under threat or coercion by any individual.
I choose to transfer
hours of VACATION CREDITS to CIP-FM:
Donor’s Name (please print): __________________________________________________________________ DSW#: ____________________
or
CIP-FM pool
Individual Recipient Identification Number (RIN):
City Department: _______________________________________________________________________ 3-letter Dept. Code: _______________
Donor’s Signature: _____________________________________________________________________ Date: ________________________________
I, ___________________________________________________________________________, declare under penalty of perjury that: (check one)
Marital Status Declaration:
PRINT NAME
I am not married
I do not know, and have taken all reasonable steps to determine, the whereabouts of my current spouse
My current spouse and I have executed a marriage settlement agreement pursuant to Title II of Part 5 of Division 4
of the California Civil Code (or a predecessor statute, if applicable) which makes my earnings my separate property.
Donor’s Signature: ___________________________________________________________________________ Date: ______________________________
I, ______________________________________________________________________, declare under penalty of perjury that I am the legal
Or Spousal Consent:
PRINT NAME
spouse of _________________________________________________________, and I have been informed of my spouse's transfer of
DONOR’S NAME
vacation credits as an irrevocable donation to a City employee designated as having a catastrophically ill family
member, and I hereby consent to this transfer by my spouse.
Spouse’s Signature: __________________________________________________________________________ Date: ______________________________
TO ENSURE CONFIDENTIALITY, send the original directly to the attention of payroll:
San Francisco Unified School District
Office of the Controller
SFUSD EMPLOYEES ONLY:
ALL OTHER CITY EMPLOYEES:
135 Van Ness Ave. Rm. 101, SF, CA 94102-5207
Payroll/Personnel Services Division
One South Van Ness Ave. 8
Floor, SF, CA 94103
th
S.F. Community College
OR
33 Gough St., SF, CA 94102-1214
DONOR: keep a copy of this form for your files, and provide a copy to your department payroll supervisor.