Request for Cash Out of Vacation Leave Reset

Request for Cash Out of
Vacation Leave
(SEIU Represented Employees Only)
Office of Human Resources
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):
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
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:
HR Business Center Signature
- Hours cashed out:
= Balance after cash out:
x Hourly rate
= Total dollars
(must be 80+ hours)
Activity Code:
Printed Name
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
revised 07/08/14