|Employee Name:||Employee Number:|
|Effective Date of Retirement:|
The above-named employee will be paid for unused accrued leave while his/her disability retirement is pending. The following is our representation of the amount of leave that this individual has accrued as of the last working day of the month prior to his/her application for disability retirement.
Number of sick days or hours: __________________ day/hours
Number of vacation days or hours: _______________ day/hours
I certify that the information provided herein is accurate. It is understood that it will be the agency's responsibility to revise the current retirement application to include any leave accruals used in the service credit and the average salary.
|Authorized Agency Signature||Date|
|Print Name||Phone Number|
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