University of Kentucky
Temporary Disability Leave/Retirement Conversion Form
FOR EMPLOYEES WITH A MINIMUM OF 66 TEMPORARY DISABILITY LEAVE
DAYS AT RETIREMENT
Name _______________________________ SSN/SAP ID _____________________
Dept. # ________________ Dept. Name ____________________________________
_____________________________________________________________________________________
Check appropriate boxes and enter salary information:
Payroll area:
□ BW
□ MO
Basic Hourly Rate $__________
Basic Hourly Rate $__________
If BW, scheduled work week:
□ 37.5 hrs
□ 40 hrs
*if BW work week is other than 37.5 or 40 hrs, contact Employee Benefits Office for assistance
Retirement Date: ________________
Temporary Disability Leave (TDL) Total in Hours:
____________
__
______________________________________________________________________________________
I. Converting TDL hours to Full Pay Policy.
(HR Policy and Procedure 87.1.b)
Up to 22 days of the TDL balance may be converted to full pay. The maximum amounts
to be converted are: 165 hours for 37.5 hr work week and 176 hours for 40 hr work week.
(a) Enter the number of Leave hours to be converted ___________.
(b) Multiply hours entered in (a) above times basic hourly rate $_____________.
II. Converting balance of TDL hours to normal retirement contribution percentage (10%).
(HR Policy and Procedure 87.1.a)
(a) Subtract hours entered in I (a) above from the total leave amount __________.
(b) Multiply basic hourly rate times the appropriate employer contribution
retirement percentage (10%) $_________________.
(c) Multiply hours in II (a) above times the adjusted hourly rate in II (b) above
$_________________.