HomeMy WebLinkAboutCSEA Employee to Employee Sick Leave Donation Form CSEA EMPLOYEE TO CSEA EMPLOYEE SICK LEAVE DONATION FORM
This form is to be used exclusively for CSEA represented Town employees exercising his/her
right to donate his/her Sick Leave Accruals to another CSEA represented Town employee as
permitted through a fully executed Memorandum Of Agreement entered into between the Town
of Southold and CSEA on September 10, 2003.
TO BE COMPLETED BY EMPLOYEE
This form is to be completed and forwarded directly to your Department Head for processing.
Contributor
Date: Name:
Address:
Department: Work Location:
Civil Service Job Title:
Recipient
Name:
Department assigned: Work Location:
I, , as a member of the CSEA Unit 8785 Collective Bargaining Unit,
having a minimum of twenty (20) days of personally accrued Sick Leave Days, hereby donate
Sick Days to the Recipient noted above upon receipt of my department head or his/her
designee. I understand that any donated days not used by the Recipient at the time of his/her
separation of service with the Town will be deposited directly into the CSEA Unit Sick Bank.
Signature Date
TO BE COMPLETED BY THE CONTRIBUTOR'S DEPARTMENT HEAD
This section is to be completed and the original forwarded to the Town Clerks Office, one (1)
copy to the CSEA Unit President or his/her designee. The Town Clerk shall forward one (1)
copy of the form stamped "received" each; to the Department Head of the"Recipient"who shall
reflect the addition of the donated Sick Day(s) to the "Recipient's" Sick Leave Accruals and one
(1) copy to the CSEA Unit President.
Date: Department:
Completed by: Job Title:
Employee's Sick Day Accruals (prior to donation):
Number of days deducted from the employee Sick Day Accruals:
Signature Date
TO BE COMPLETED BY THE RECIPIENT'S DEPARTMENT HEAD
Date: Department:
Completed by: Job Title:
NOTE:THESE DAYS MAY ONLY BE USED WHEN ALL OTHER PERSONAL LEAVE ACCRUALS HAVE BEEN EXHAUSTED.
2015-04b Employee-Employee Donation Form