Hourly Employee Purchased Leave Time (HEPLT)
Salary Reduction Request Form
Instructions: Use this form if you elect to participate in the University of St. Thomas (UST) Hourly Employee Purchased
Leave Time (HEPLT) program and wish to request approval to reduce your salary and direct this salary to become HEPLT.
Employee Information
Employee Name:
Phone Number:
Department:
UST ID:
FTE:
Total HEPLT Hours Requested for Purchase
I am requesting the approval to purchase HEPLT hours at my hourly rate of pay in effect on January 1 or upon my date of
hire with before-tax dollars to be spread out over my scheduled calendar year pay periods.
The number of hours purchased are based on your FTE. For example:
1.0 FTE = minimum of 8 hours up to a maximum of 40 hours purchased
.625 FTE = minimum of 5 hours up to a maximum of 25 hours purchased
.5 FTE = minimum of 4 hours up to a maximum of 20 hours purchased
HEPLT Purchase Agreement
I hereby apply to participate in the Hourly Employee Purchased Leave Time Program as described in the online
Summary Plan Description for the HEPLT Program. I understand that my participation is voluntary and will
begin at the earliest possible pay period following approval. I further understand that once I enroll in the
Program, I must continue my participation through the end of the calendar year for which this agreement applies.
By making this request and signing this form, I agree to be bound by the provisions of the Program. I further
consent to the University of St. Thomas recovering any overpayments I owe the Program through payroll
deduction or adjustments to my purchased leave time balance.
Employee Signature:_________________________________________________________________________ Date: __________________
Management Approval
Approved
Not approved (reason) : _________________________________________________________________________
Immediate Supervisor Signature: __________________________________________________________ Date: _____________________
Department Head Signature: _______________________________________________________________ Date: _____________________
Submit completed request form to the Human Resources Department, AQU217
For Payroll Use Only
_________________________
Employees Hourly Rate
x
_________________________
HEPLT Hours Purchased
(above)
=
_________________________
Pre-tax Annual Cost
_________________________
Pre-tax Annual Cost
÷
_________________________
26 Annual Pay Periods
or Pro-rated
=
_________________________
Pre-tax Cost per
Pay Periods