_______________________________________________ _________________________
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
Name of Donating Employee*:
W# of Donating Employee*:
State Hire Date:
* Your full Name and Workday Number (W#) are required to help verify your identity. Failure to provide it may result in delays and/or rejection of this
request. This information is kept confidential.
Donating Employee’s Agency Name:
Agency Division:
RECEIVING EMPLOYEE’S INFORMATION:
Name of Employee:
Employee’s Agency Name:
TYPE OF LEAVE DONATED: TOTAL HOURS DONATED:
LEAVE BALANCE AFTER
DONATION:
[ ] SICK**
[ ] ANNUAL
[ ] PERSONAL
I understand that if the employee to whom I am donating leave does not use the leave for any reason, the unused
donated leave shall be returned to my leave balances by my Appointing Authority.
Signature:
Date:
PART I - TO BE COMPLETED BY DONATING EMPLOYEE
(Please TYPE or PRINT with black or blue Ink)
** If you are donating sick leave, you must maintain a balance of at least 240 hours of sick leave after
the donation is deducted.
CERTIFICATION OF LEAVE FOR DONATING EMPLOYEE –
TO BE COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
ANNUAL/PERSONAL LEAVE CERTIFICATION: I have reviewed this employee’s leave balances and
affirm that s/he has sufficient annual/personal leave to make this donation.
SICK LEAVE CERTIFICATION: I have reviewed this employee’s sick leave balance. I affirm that s/he will
have a sick leave balance of at least 240 hours after this donation. As the Appointing Authority/Designee for
the employee making the above leave donation, I certify this donation is in compliance with COMAR
17.04.11.22 C (3).
APPOINTING AUTHORITY/DESIGNEE DATE
(Per COMAR 17.04.11.22 C (11) The appointing authority of an employee who donates leave shall adjust the
donating employee’s leave balance before forwarding a copy of the MS 405 form to the receiving employee’s
appointing authority. If the receiving employee is denied the use of donated leave, the receiving employee’s
appointing authority shall notify the donating employee’s appointing authority within 7 days of the denial, and the
donating employee’s appointing authority shall restore the leave balance of the donating employee within 14 days
of notification from the receiving employee’s appointing authority.)
*****************NOT VALID WITHOUT TIMEKEEPER CERTIFICATION******************
__________ Hours of selected LEAVE DONATED were deducted from balance on _______________(date)
by ___________________________________________________(Timekeeper name)/____________(initials)
Page 1 of 2 MS 405 (Rev.2/2023)
EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM - REQUEST FORM
PART II - TO BE COMPLETED BY EMPLOYEE RECEIVING LEAVE DONATIONS
(Please TYPE or PRINT with Black or Blue ink)
Name*: Workday #*: W ___ ___ ___ ___ ___ ___ ___
* Your full Name and Workday Number (W#) are required to help verify your identity and process your Request. Failure to provide it may result in delays and/or
rejection of your request. This information is kept confidential.
Job Title and brief description of duties:
Home Address:
City/State/Zip:
Agency Name:
Request Type:
□
New
□
Extension
Reason for Request:
□ An illness or disability of the employee due to a serious and prolonged medical condition that existed at the time
the leave was donated;
or
□ A catastrophic illness or injury of a member of the employee's immediate family for whom the employee is needed
to provide direct care**.
**
For family member please provide
- Name: Relationship:
*
*Describe care to be provided:
Sig
nature:
Da
te:
MUST BE COMPLETED BY AGENCY LEAVE BANK/DONATION COORDINATOR
Leave Bank/Donation Coordinator: Email:
Phone #: Fax #: Employee Hire Date:
Last Day Employee Worked: ___________ Dates to Cover: From: ___________ Through: ___________
Donations Received: _________ Hours Hours Needed: __________ Hours
Is employee on FMLA leave? No □ Yes □ If Yes, provide end date of current FMLA:
Has the employee been seen by the State Medical Director? No
□
Yes
□ If Yes, provide copy of SMD Report
Leave Coordinator’s Signature: Date:
MUST BE COMPLETED BY APPOINTING AUTHORITY/DESIGNEE
As the Appointing Authority/Designee for the employee receiving the leave donation, I certify that this employee has
exhausted all forms of annual, sick, personal and compensatory time because of a serious and prolonged medical condition.
Approval will not cause the employee to exceed 2,080 hours of leave from the Leave Bank and/or Employee-to-Employee Leave
Donation Programs during his/her entire State employment. Approval will not cause the employee to exceed 16 months of
continuous leave, when combined with all other forms of paid leave. As the appointing authority or designee for this employee,
I have reviewed the employee’s records and I certify that this request meets all of the criteria specified in this Section.
______________________________________________________________ ______________________________________
Signature of Appointing Authority or Designee Date
Page 2 of 2 MS 405 (Rev. 2/2023)