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