Employee name:                            

I authorize CFD, under the outlined conditions, to transfer the following leave to the recipient’s donated leave bank.

Conditions:

• Donated hours cannot be more than 50% of my current earned balance.
• Hours donated on an hour-for-hour basis in four-hour increments.
• The hours are donated to a recipient who meets the eligibility requirements.

Donation To:          Number of Hours Donated:  

I would like my donation to remain anonymous:

Verification of Eligibility

To be completed by Human Resources

Employment Year:                                         

Current PTO/Sick Leave Balance:                  

Current Earned PTO/Sick Leave:                 

Previously Donated Hours:                           

Total Donated PTO/Sick Leave Approved:   

Total PTO/Sick Leave Remaining:                 

Transfer made for the following pay date: