![](media/image1.png){width="1.5in" height="0.32708333333333334in"}
**[Vacation Donation Program]{.smallcaps}**

[Request to Donate Vacation]{.smallcaps}

+-------------------------------+----------+--------------------------+
| **[Donor                      |          |                          |
| Information:]{.smallcaps}**   |          |                          |
+-------------------------------+----------+--------------------------+
| [Donor's Name (Last, First,   | [        | [E-mail                  |
| M.I.)]{.smallcaps}            | Employee | Address:]{.smallcaps}    |
|                               | ID:]{.sm |                          |
| [     ]{.smallcaps}           | allcaps} | [     ]{.smallcaps}      |
|                               |          |                          |
|                               | [        |                          |
|                               |    ]{.sm |                          |
|                               | allcaps} |                          |
+-------------------------------+----------+--------------------------+
| [Recipient's                  |          |                          |
| Name:]{.smallcaps}            |          |                          |
|                               |          |                          |
| [     ]{.smallcaps}           |          |                          |
+-------------------------------+----------+--------------------------+
| I hereby authorize the        |          |                          |
| transfer of                   |          |                          |
| [     ]{.underline} vacation  |          |                          |
| days to the above named leave |          |                          |
| recipient.                    |          |                          |
|                               |          |                          |
| -   I certify that this       |          |                          |
|     donation does not cause   |          |                          |
|     my vacation balance to    |          |                          |
|     drop to one-half the      |          |                          |
|     amount I will accrue this |          |                          |
|     vacation year.            |          |                          |
|                               |          |                          |
| -   I certify that the leave  |          |                          |
|     recipient is not my       |          |                          |
|     Supervisor.               |          |                          |
|                               |          |                          |
| -   I acknowledge that once   |          |                          |
|     this form is submitted,   |          |                          |
|     the donation of leave is  |          |                          |
|     not revocable.            |          |                          |
|                               |          |                          |
| -   I understand that my      |          |                          |
|     donation is not           |          |                          |
|     tax-deductible per        |          |                          |
|     Internal Revenue Service, |          |                          |
|     Letter Ruling 9051005.    |          |                          |
|                               |          |                          |
| -   I acknowledge that I have |          |                          |
|     not been directly or      |          |                          |
|     indirectly intimidated,   |          |                          |
|     threatened or coerced, or |          |                          |
|     promised any benefit by   |          |                          |
|     any employee for the      |          |                          |
|     purpose of donating or    |          |                          |
|     using leave.              |          |                          |
|                               |          |                          |
| -   I acknowledge that I have |          |                          |
|     read the Fermilab         |          |                          |
|     Vacation Donation Policy. |          |                          |
|                               |          |                          |
| [[                            |          |                          |
|                               |          |                          |
|                 ]{.underline} |          |                          |
| [                             |          |                          |
|    ]{.underline}]{.smallcaps} |          |                          |
|                               |          |                          |
| [Donor's Signature            |          |                          |
| Date]{.smallcaps}             |          |                          |
+-------------------------------+----------+--------------------------+
| **[Privacy                    |          |                          |
| Statement:]{.smallcaps}**     |          |                          |
+-------------------------------+----------+--------------------------+
| Participation in this program |          |                          |
| is voluntary. The information |          |                          |
| furnished will be used to     |          |                          |
| identify records properly     |          |                          |
| associated with the transfer  |          |                          |
| of vacation time. This form   |          |                          |
| will be retained by Fermilab  |          |                          |
| for a period of one year from |          |                          |
| the date the leave transfer   |          |                          |
| is executed.                  |          |                          |
+-------------------------------+----------+--------------------------+
| **[Submit Completed Form to   |          |                          |
| Employee Relations            |          |                          |
| Department]{.smallcaps}**     |          |                          |
|                               |          |                          |
| **[scan and email             |          |                          |
| <hsidman@fnal.gov> \| fax     |          |                          |
| 630.840.2306 \| mail station  |          |                          |
| 124]{.smallcaps}**            |          |                          |
+-------------------------------+----------+--------------------------+

  -------------------------------------- --------------------------------
  **[For Use by Human Resources          
  Only:]{.smallcaps}**                   

  [Request Approved:]{.smallcaps}        [Date Processed:
  [yes]{.smallcaps} [No]{.smallcaps}          ]{.smallcaps}
  -------------------------------------- --------------------------------