DEPARTMENT OF ECONOMIC OPPORTUNITY

Sick Leave Pool Donation Request
(Must be a participating Sick Leave Pool Member)

Name (Last, First, Middle Initial)	People First ID	Date
Cost Center #	Date of Termination/Retirement	Number of Hours Donated
(16 hours maximum)

I, , certify that this is a voluntary donation to the Department Sick Leave Pool.

Signature
Date

Please forward to the following address:

Department of Economic Opportunity

Human Resource Office

Caldwell Building, MSC #140

107 E. Madison Street

Tallahassee, Florida 32399-4127

(Rev.09/11)

DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

J0JEM

2008-01-17

mcgillj

FDLES J&B OIT