Consent to receive vacation/PTO donations

Giving consent does not guarantee donations.

Employee information

Employee's first and last name

Employee ID (must be no more than 9 digits)

Home phone number

Personal email (in case we can't reach you at your work email)

Leave information

Leave for birth/adoption?

Yes
No

If yes, due date or placement date

mm/dd/yyyy

Leave for death of family member?

Yes
No

If yes, date of death

mm/dd/yyyy

Leave for your own or a family member's illness or injury?

Self
Family member

If yes, anticipated leave start date

mm/dd/yyyy

Anticipated leave end date

mm/dd/yyyy

Supervisor information

Supervisor name

Supervisor work phone

Supervisor email

Voluntary request for your name to be posted on an internal donation page

The employee request for vacation/PTO donation page is an employee driven page and names are posted by employee request only. Posting of names on this page is not intended in any way to confirm the legitimacy of a request or show favoritism of one employee over another.

Visit the page (must have network access).

Vacation/PTO donation posting page conditions:

Posting will be valid for 60 days
The posting does not guarantee donations
To extend the posting beyond 60 days, submit a new request
Names may be viewed by any employee of Hennepin County
To remove your name before 60 days is up, request it in writing to an HR leave specialist at hr.lam.office@hennepin.us and it will be removed within one working day from the date the request is received

Type your name as you want it be listed on the intranet site

Expected date of return

mm/dd/yyyy

Department name

Date

mm/dd/yyyy

I agree to the terms

Yes

Other

Questions or comments

Signature

Having read and understood the description of the Hennepin County vacation/PTO donation program, I agree to accept the value of vacation/PTO hours donated in my name. I understand that this consent is valid until I cancel it in writing or no longer qualify to participate in the program.

Name

I accept these terms.

Yes

Date

mm/dd/yyyy

If you receive donations:

You won’t know who made the donations since we keep donor names confidential
You receive donations in cash at the donor’s pay rate
Donations are taxed
You receive donations beginning the pay period you use up all your paid leave and you’ll see donation earnings on your pay stub
PERA deductions are not taken out
Insurance premiums are taken out (except when donations aren’t high enough to cover them, or you’re on unpaid medical leave or medical layoff)
Court orders related to wages apply
Donations can’t go above your regular earnings. If donations put you over your regular earnings, extra donations would apply, if needed, to future paychecks.
Donations are applied to current and future pay periods, not previous pay periods
Pregnancy and childbirth: Employees (female and male) can normally receive donations up to six weeks after delivery or have a doctor’s note if after six weeks
For a family death, you can receive donations for two pay periods after the death
You can reverse your consent to receive donations by emailing an HR leave specialist at hr.lam.office@hennepin.us
Donations are valid for one year from the donation date
Donations don’t affect short- or long-term disability, PERA disability or Social Security disability
MERF (Minneapolis Employees Retirement Fund) members who receive donations can’t receive MERF disability or retirement benefits at the same time
1% Supplemental Retirement Plan participants have their contribution taken out and matched