Request to Donate Sick Leave
Name
*
First Name
Last Name
Email
*
example@example.com
Department
*
Please state below the number of hours of sick leave you would like to donate to the medical emergency sick leave bank:
*
I understand:
Donated sick time is voluntary and cannot be returned to me
Donating time will reduce my available accrued/unused sick time by the hours indicated above
Per IRS guidelines, I may not claim a tax deduction or charitable contribution for any donated sick leave
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: