Gaithersburg Request For Advancement Of Sick Leave (Page 2 of 2) in pdf

Gaithersburg Request For Advancement Of Sick Leave Page 2

RECOVERY OF EMPLOYEE DEBT AUTHORIZATION FORM

Employee Name:

Employee ID No.:

Department: ___________________________________ Job

Title: ________________________

I hereby authorize the City of Gaithersburg to initiate a payroll deduction from any unpaid salary,

accrued annual leave, compensatory time, or retirement contributions owed to the employee.

In the event an employee is separated from City employment before the debt to the City is repaid, the

remaining portion of unearned paid sick leave shall be deducted from the employee's unpaid salary,

accrued annual leave, compensatory time, or retirement contributions owed to the employee.

Employee signature:

Date:

==========================================================

Human Resources verifies that the City is in receipt of Medical documentation that has been approved by

the Human Resources Department.

Human Resources Director: _______________________________

Date:

Approved

Not Approved

Department Head: _______________________________________

Date:

Approved

Not Approved

City Manager: ___________________________________________

Date:

Approved

Not Approved

S:/HR/Forms/Request for Advancement of Sick Leave Form (10/2011)

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Gaithersburg Request For Advancement Of Sick Leave Page 2