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GEER THE SCHOOL DISTRICT OF PALM BEACH COUNTY 1O) Sick and /or Annual Leave Transfer Request \wese’/ for Eligible District Employees ‘School Board Policy 3.80 allows for an employee to transfer accrued sick leave and, if applicable, accrued annual leave as fick leave, Specific conditions are outined in School Board Policy 3.80 Transfered leave canno} benoft the rocpisn! cath bisther sick leave balance has been depleted and, i applicable, annual leave balance has been depleted. This beret ieuiso available to employees winose bargaining unit hes negotiated this benefit tobe included in thei labor contract ‘To authorize the transfer of leave from one eligible employee to another eligible employee as sick leave, this form must be ‘Completed and submitted by the empioyee to the Department of Compensation & Employee Information Services, Iftransfer request exceeds 24 hours the recipient must submit a medical certication to support the transfer request. The ‘mesial cerfication must include the employees name, condition and duration to suppor the transfer request SECTION I- Transferring Employes The transferring employee is the eligible omployee who wants to transfer sick andor, i applicable, annual leave to another oligible employee as sick leave, + Accrued sick andlor annual leave balance will be reduced by each transfer. + Oath and signature are required to authorize the transfer and must be notarized. Employee Name (ast, rst male) Employee DF Employee PosttonTite Employes Work Location Number of hours of; a) sick leave to be transferred ») annual leave tobe transferred as sick leave | solemnly swear and truthiully affim that | am an eligible employee who wishos to transfer the numberof sick and/or annual {eave day(s) as indicated above tothe eliible employee (as listed in Section Il) as sick leave. | understand that any false statement on this form will result in disciplinary action eter i Signatur of Employee Transfering Leave Date SECTION I A-To be completed by a Notary Public STATE OF FLORIDA, COUNTY OF ‘Sworn to and subscribed to me this day of ty Who is personally known to me or who has produced + 35 enification, ‘Signature of Noary Pubic Date rit Nome Expiration Date SECTION Il Recipient Employes Recipient employee is the eligible employee who will receive transferred sick leave and, if applicable, annual leave transferred 88 sick leave from anther eligible employes. + Employee must be in a postion that is eligible to accrue sick leave, + Employee must deplete sick leave and, if applicable, annual leave before transferred leave can occur. Employee Name (ast, fst mice) Employes OF ‘Anna Levy 1128222 Ernployee Postion/Tite Employee Werk Location Teacher Starlight Cove Elementary School PBSD 2175 (Rev. 02/1/2018) ORIGINAL - Compensation & Employee Information Services,