Employee Name: _______________________________________	Date: _____________________

You must donate a Minimum of four (4) hours and a Maximum of forty (40) hours or fifty (50) percent (%) of your current balance.

DONATION DETAILS	HOURS
Current Vacation Balance
# of Hours to Donate (Use Negative Number)
Remaining Balance

I understand that once I have given this time to the Charitable Sick Bank I WILL NOT, under any circumstances, be permitted to receive this time back.

My signature below constitutes my authorization to deduct the above time from my vacation balance and credit them to the Charitable Sick Bank.

Employee Signature: _____________________________________________

-------------------------- HR Use Only Below This Line --------------------------------

Date Processed:

Approve ☐	Declined ☐	Reason: __________________________

# Donated Hours
Hourly Rate
Cash Value of Donation