Moore
Content
STATE OF CALIFORNIA
CATASTROPlllC
CDC 869 (11/88) PLEASE PART
DONOR
TIME BANK DONATION AUTHORIZATION
PRINT OR TYPE A - DONATION
TO COMPLETE
DEPARTMENT OF CORRECTIONS DISTRIBUTION: ORIGINAL -RECIPIENTS PERSONNEL OFFICE GREEN- DONOR PIO SECOND NOTICE CANARY - DONOR SECOND NOTICE PINK - DONOR PIO FIRST NOTICE GOLDENROD - DONOR FIRST NOTICE
INFORMATION
ALL COPIES TO YOUR PERSONNEL OFFICE DONOR INFORMATION RECIPIENT INFORMATION
PART A_ SUBMIT
DONOR'S
FULL NAME
SOCIAL SECURITY
NUMBER
RECIPIENTS
FULL NAll-IE
POSITION
NUMBER
BARGAINING
UNIT
STATE
AGENCY
VACATION
ANNUAL
LEAVE
PERSONAL
HOLIDAY
HOLIDA Y CREDIT
CTO·
OTHER
(SPECIFY)
I certify that I have sufficient leave credits currently of this donation and my personal leave usage for the automatic establishment and collection of an accounts amount will be automatically deducted from my next
DONOR'S SIGNATURE
available to make this donation. I understand that this donation is irrevocable. If the combination pay period from which these credits are deducted exceeds my available credits, I authorize the receivable based on the number of leave credits overused. I understand that the full net dollar available pay warrant(s) until the overpayment is collected in full.
PHONE NUMBER DATE
CLASSIFICATION
YOUR NAME WILL BE IDENTIFIED AS A DONOR UPON REQUEST OF THE RECIPIENT UNLESS YOU CHECK THE BOX REQUESTING ANONYMITY.
D
I REQUEST
ANONYMITY_
DATE RECEIVED
I
PART B - DONOR'S
PART B. RETAIN
PERSONNEL
PINK COPY.
OFFICE
GIVE GOLDENROD COPY TO DONOR FORWARD REMAINING COPIES TO RECIPIENT'S PERSONNEL OFFICE.
COMPLETE
WAS THE ABOVE
DONATION
DEDUCTED
FROM
THE DONOR'S
LEAVE
BALANCE(S)?
PA Y PERIOD(S).
D D D
SIGNATURE
YES - ALL
leave credit(s) donated were deducted from the donor's balances
I
TYP&HOURS
DEDUCTED
during the
YES - PARTIAL
balances
leave credit(s) donated were deducted from the donor's during the The following were NOT deducted.
MAXIMUM ALLOWED
PAY
PERIOD(S).
TYPElHOURS
NOT DEDUCTED
Leave credit(s) donated were NOT accepted because:
NO -
BY UNIT CONTRACT A VAlLABLE
ALREADY
DONATED
I--I--INSUFFICIENT OTHER CLASSIFlCA nON LEAVE CREDITS
(SPECIFY) PHONE NUMBER DATE
DATE RECEIVED
PART C - RECIPIENT'S
COMPLETE PART C. RETAIN
PERSONNEL
ORIGINAL.
OFFICE
AND GREEN COPIES TO DONOR'S PERSONNEL OFFICE.
SEND CANARY
WAS THE ABOVE
DONATION
USED BY THE RECIPIENT?
PAY PERIOD(S).
D D D
SIGNATURE
YES - ALL
leave credit(s) donated were used during the
YES-PARTIAL
leave credit(s) donated were used during the
PAY
PERIOD(S).
The following were NOT used and are hereby returned to the donor.
TYPElHOURS
RETURNED
NO - Leave credit(s) donated were NOT needed and are hereby returned to the donor.
CLASSIFICATION PHONE NUMBER DATE
CATASTROPlllC
CDC 869 (11/88) PLEASE PART
DONOR
TIME BANK DONATION AUTHORIZATION
PRINT OR TYPE A - DONATION
TO COMPLETE
DEPARTMENT OF CORRECTIONS DISTRIBUTION: ORIGINAL -RECIPIENTS PERSONNEL OFFICE GREEN- DONOR PIO SECOND NOTICE CANARY - DONOR SECOND NOTICE PINK - DONOR PIO FIRST NOTICE GOLDENROD - DONOR FIRST NOTICE
INFORMATION
ALL COPIES TO YOUR PERSONNEL OFFICE DONOR INFORMATION RECIPIENT INFORMATION
PART A_ SUBMIT
DONOR'S
FULL NAME
SOCIAL SECURITY
NUMBER
RECIPIENTS
FULL NAll-IE
POSITION
NUMBER
BARGAINING
UNIT
STATE
AGENCY
VACATION
ANNUAL
LEAVE
PERSONAL
HOLIDAY
HOLIDA Y CREDIT
CTO·
OTHER
(SPECIFY)
I certify that I have sufficient leave credits currently of this donation and my personal leave usage for the automatic establishment and collection of an accounts amount will be automatically deducted from my next
DONOR'S SIGNATURE
available to make this donation. I understand that this donation is irrevocable. If the combination pay period from which these credits are deducted exceeds my available credits, I authorize the receivable based on the number of leave credits overused. I understand that the full net dollar available pay warrant(s) until the overpayment is collected in full.
PHONE NUMBER DATE
CLASSIFICATION
YOUR NAME WILL BE IDENTIFIED AS A DONOR UPON REQUEST OF THE RECIPIENT UNLESS YOU CHECK THE BOX REQUESTING ANONYMITY.
D
I REQUEST
ANONYMITY_
DATE RECEIVED
I
PART B - DONOR'S
PART B. RETAIN
PERSONNEL
PINK COPY.
OFFICE
GIVE GOLDENROD COPY TO DONOR FORWARD REMAINING COPIES TO RECIPIENT'S PERSONNEL OFFICE.
COMPLETE
WAS THE ABOVE
DONATION
DEDUCTED
FROM
THE DONOR'S
LEAVE
BALANCE(S)?
PA Y PERIOD(S).
D D D
SIGNATURE
YES - ALL
leave credit(s) donated were deducted from the donor's balances
I
TYP&HOURS
DEDUCTED
during the
YES - PARTIAL
balances
leave credit(s) donated were deducted from the donor's during the The following were NOT deducted.
MAXIMUM ALLOWED
PAY
PERIOD(S).
TYPElHOURS
NOT DEDUCTED
Leave credit(s) donated were NOT accepted because:
NO -
BY UNIT CONTRACT A VAlLABLE
ALREADY
DONATED
I--I--INSUFFICIENT OTHER CLASSIFlCA nON LEAVE CREDITS
(SPECIFY) PHONE NUMBER DATE
DATE RECEIVED
PART C - RECIPIENT'S
COMPLETE PART C. RETAIN
PERSONNEL
ORIGINAL.
OFFICE
AND GREEN COPIES TO DONOR'S PERSONNEL OFFICE.
SEND CANARY
WAS THE ABOVE
DONATION
USED BY THE RECIPIENT?
PAY PERIOD(S).
D D D
SIGNATURE
YES - ALL
leave credit(s) donated were used during the
YES-PARTIAL
leave credit(s) donated were used during the
PAY
PERIOD(S).
The following were NOT used and are hereby returned to the donor.
TYPElHOURS
RETURNED
NO - Leave credit(s) donated were NOT needed and are hereby returned to the donor.
CLASSIFICATION PHONE NUMBER DATE
