Appendix B - PTO Cash-In Form

898 Appendix B - PTO Cash-In Form

Effective Date:

Revision Date:

Regular full-time employees are encouraged to save at least 200 hours of PTO for emergencies. Current regular full-time employees who have accrued PTO in excess of 200 hours may request the EMS Council to cash in up to 200 accrued hours per fiscal year in excess of a 200 hour reserve. An employee may receive no more than two PTO cash-ins during each fiscal year. Requests to cash in accrued PTO will be evaluated on a case-by-case basis. Written request is made to the Executive Director on the appropriate form, who shall then forward such request with recommendation to the President. The President shall approve, deny or modify the request based on the availability of funds and other pertinent circumstances. (See Policy 3.15)

Taxes will be withheld according to the regular tax tables used in calculating your payroll unless you specify a greater amount to be withheld.

Name: ________________________________________________________

Number of hours requested to be “cashed in”: ________________________________

Amount or percentage of Federal Income Tax to withhold (if greater than standard):_____

Amount or percentage of State Income Tax to withhold (if greater than standard):_____

Employee Signature:_____________________________________________________

Date:________________________

Please print and sign this form and email or deliver to the Executive Director.

FOR OFFICE USE

ED Recommendation: _____ Approve _____ Deny _____ Modify to ____ hours

ED’s Signature:_____________________________ Date:________________

President's Action: _____ Approve _____ Deny _____ Modify to ____ hours

President’s Signature:_____________________________ Date:_______________

Policy No.  8.98  Issued  1/1/2019  Applicable  12/13/2018