Donations of PTO Form

Request for Donated PTO

I am applying to receive any PTO hours that may be donated by GSMC employees to me for a medical emergency involving:

ÿ my own health.

ÿ my immediate family member.

(If family member, provide name and relationship)

Describe the medical emergency:

I have read the guidelines for “Donations of PTO to Employees with Medical Emergencies.” I understand I must use all of my own accrued PTO benefit hours before using donated hours. I understand that any donated hours I receive will be regular taxable wages for me.

Employee Signature & Date

Department Director Signature & Date

Director of Human Resources Signature & Date

Donation of PTO

Donor’s Name

Social Security #

# Hours Donated

Donated to

Name of Recipient

I have read the guidelines for “Donations of PTO to Employees with Medical Emergencies.” I understand that I am donating hours from my Personal Time (PT) account that are currently accrued and available to me, and that I am forfeiting my future use of these benefit hours. I understand that my PT account balance may not be reduced to less than 100 hours by making this donation. I have not been coerced by any GSMC employee or manager to make this donation.

___ The recipient may be informed of

my donation.

___ Please keep my donation confidential.

Donor’s Signature & Date

Human Resources Action Taken:

_______ hours transferred from Donor’s PT account to Recipient’s PT account on ____________ (date).

Initials

_______ unused hours returned to Donor’s PT account on ____________ (date).

Initials