Direct Sick Leave Donation – DONOR (completed by Donor employee) Donor’s Name: Banner ID: Recipient’s Name: Banner ID: (if known) By signing this form, I understand and agree to the following statements. 
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My donation is strictly voluntary. My donation will result in a deduction to my own personal sick leave balance. Unused hours by the recipient will not be returned to my available sick leave balance. As prohibited by state law, I have not and will not receive any remuneration or gift in exchange for donating sick leave. (Texas Government Code Section 661.207)  The dollar value of the donated sick leave will be included in my income by Texas Tech University System and taxes will be withheld from my payroll earnings. Hours to be donated. (NOTE: Hours will be converted to dollar value of donated leave.) I understand the dollar value of donated sick leave will be included in my taxable income and taxes will be withheld from my payroll earnings. (FIT and FICA withholding up to 32.65%. Additional 0.9% will be withheld if Medicare threshold has been met for the calendar year) (Donor Initials)
I would like to remain anonymous to the recipient. (Donor Initials)
Donor’s Signature Date I confirm that the donor has sufficient sick leave hours to donate and donor’s labor FOP(s) will be used for FICA match. (Department
Head Initials)
Department Head/Director Signature Date Please return completed form to Payroll & Tax Services, webmaster.payroll@ttu.edu.