Recipient

                   Name:                          ___________________________________________________

                   Position:                       ___________________________________________________

                   Department/School:   ___________________________________________________

Donor

                    Name:                         ____________________________________________________________

                    Social Security #:        ________________________________ Bargaining Unit _____________

                    Department/School:   ____________________________________________________________

                    Leave Hours Donated:  Sick Leave Hours  _________   Vacation Leave Hours ___________

                        I agree to donate the leave hours indicated above, not to exceed 40 hours (depending upon bargaining unit) in a fiscal

                        year from my accrued leave credits for use by the Recipient who has suffered a catastrophic disability.

                    Donor’s Signature:_______________________________ext.    _________      Date: _____________

                     Payroll Use Only

                          Recipient’s Social Security #:  __________ - _______ - __________

                          Hours Required: _____       Hours Accepted: _____  Sick Leave _____ Vacation Leave

                          Recipient’s Leave accruals for use as noted above.

Leave Records Noted:  _____ Recipient _____ Donor

                                                                                Copies:     _____ Donor   _____Timekeeper     _____Human Resources Mgmt.   _____ Faculty Affairs