Request for Cash Out of Vacation Leave Reset (SEIU Represented Employees Only) Office of Human Resources Employee Complete this section, sign and date the form; send to the Human Resources staff in your Business Center. Last Name First Name Middle Name University ID Number of vacation leave hours to cash out (not to exceed 40): Department I am submitting this request to cash out the vacation hours noted below as allowed under Article 47, Section 17 of the Collective Bargaining Agreement between the Oregon University System and SEIU, OPEU Local 503. My signature below indicates that I understand and agree to the following: 1. I may cash out up to 40 hours of vacation leave annually. 2. My request must be made in December. 3. After the cash out, I must have at least 80 hours of accrued vacation leave remaining. 4. Cash out payment is subject to ordinary deductions and withholdings. 5. This request is irrevocable. 6. I will receive this pay on my January paycheck. Employee Signature Date Business Center - Human Resources Complete this section; then send to the payroll staff in your business center. Balance before cash out: Hours cashed out: Pay Month: JAN HR Business Center Signature - Hours cashed out: = Balance after cash out: x Hourly rate = Total dollars Index: (must be 80+ hours) Activity Code: Printed Name Date Phone Business Center - Payroll Complete this section; then return to your Human Resources Business Center for imaging. During time entry (January 17 and 18, 20XX), submit the cash out payment in PYAHOUR with the LPV earn code. Payroll Business Center Signature Printed Name Date Phone revised 07/08/14