UNIFORMED SERVICE SHARED LEAVE POOL – RECIPIENT REQUEST FORM INSTRUCTIONS
Complete the attached form if you have been called to active duty in a uniformed service of the United States and you wish to request leave from the Washington state’s Uniformed Services Shared Leave Pool (USSLP).
To be eligible for shared leave from the USSLP the following conditions must be met:
; There must be leave available in the pool
; You have or will shortly deplete your paid military leave, compensatory time, vacation leave, and
; Your monthly military salary [as defined in WAC 357-31-650(4)] is less than your state monthly salary
[as defined in WAC 357-31-650(5)]. However, up to eight hours per month may be used from the pool,
to continue coverage under the Public Employee’s Benefit Board regardless of the employee’s monthly
state salary and military salary.
After you complete the “Recipient’s Information”, retain a copy of the form and submit the form to the Human
Resources Operations Office that serves your department. If you do not know which office that is, ask your department’s administrator.
UNIVERSITY of WASHINGTON
UNIFORMED SERVICE SHARED LEAVE POOL – RECIPIENT REQUEST FORM
RECIPIENT’S INFORMATION (To Be Completed by Requestor) Print Recipient’s Name (Last, First, MI) UW Employee ID Number E-mail Address
Agency/Institution Address Contact Phone # University of Washington - - Power of Attorney (POA) POA Contact Phone # POA E-mail Address
(If applicable – Attach copy)
WHY IS SHARED LEAVE NEEDED?
Maintain the level of state compensation consistent with the amount that would have been received if I remained in
active state service
Maintain the level of state compensation and employee benefits
Maintain employee benefits (8 hours per month)
STATE SALARY INFORMATION
Is most recent state earnings statement attached? Yes No (Explain) U of W does not provide printed earnings
Is the earnings statement you provided representative of your normal earnings? Yes No - How is this statement
Do you receive any of the following: Special Pay Shift differential Other (Explain) MILITARY SALARY INFORMATION
Are your military orders attached? Yes No (Explain) Is your Military Leave & Earnings Statement Attached? Yes No (Explain) Military Pay Summary – Please provide the following military salary information
The definition for military salary for the purposes of the Uniformed Service Shared Leave pool is the base, specialty, and
other pay but does not include allowances such as the basic allowance for housing.
Branch of Service Length of Deployment Rank Total Years of Service
Base Pay Specialty Pay Other Pay
Command Contact to verify Military Salary Command Phone # Command E-mail
ANTICIPATED STATE OR MILITARY SALARY CHANGES
Anticipated State Salary changes: Anticipated Military Salary changes:
By my signature, I certify that this information is true and complete to the best of my knowledge. Additionally, I authorize the Military Department to contact my Command at any time during my activation to verify military pay information. Finally, I understand that if I am approved for Uniformed Service Shared leave “to make up a salary difference”, I have a responsibility to notify the Military Department of any changes to my military and/or state salary or military orders.
______________________________________________________________________ Name Date:
PERSONNEL / PAYROLL INFORMATION
(To be completed by the UW Human Resource/Payroll Office) Verify UW Employee ID Number Date Form Received from Employee
STATE SALARY INFORMATION
Job Classification or Job Title Base Salary Rang/Step if Applicable Is the employee Represented?
Special Pay Shift Differential Next PID
Vacation Personal Holiday Military Leave
Name of Human Resource Contact Phone E-mail
Name of Payroll Contact for Leave Transfer Phone E-mail
By submission of this form, I certify that the recipient meets all of the criteria required in RCW and that they followed
agency / institution policy and procedures to be eligible for leave donations.
Name Title Date
Human Resources/Payroll forward completed form to:
Washington Military Department
State Human Resource Office
Camp Murray, Bldg # 33, Tacoma WA 98430-5006
Fax: (253) 512-7808
Questions may be directed to Military Department Human Resources at 253-512-7522. The Public Records Act, RCW 42.17.250, et.seq. requires disclosure of public records unless they are exempt. If requested, non-exempt public records in the possession of the Department of Personnel will be released. Exempt records will be withheld from public disclosure or exempt portions of records will be redacted from records prior to release.