UMHHC Payroll
University of Michigan Health System
Paid Time Off Sell Back Request Form
Form must be completed and returned to department Timekeeper/Supervisor by:
END OF THE BENEFITS OPEN ENROLLMENT PERIOD: For Non-exempt, Nonbargained for
DECEMBER 1: For nurses covered under the UMPNC/MNA bargaining agreement
NAME
UM EMPLOYEE ID NUMBER
JOB TITLE/DEPARTMENT
NUMBER OF HOURS YOU WISH
TO SELL BACK (no partial hours)
MINIMUM BALANCE YOU WISH
TO MAINTAIN (IF GREATER THAN
REQUIRED HOURS)
MNA ONLY- NUMBER OF HOURS
YOU WISH TO DONATE TO THE
TO THE PTO DONATION PROGRAM
May donate in increments of two (2) hours per new agreement between HSHR and UMPNC effective 9/1/12
See MNA contract page 184 for details regarding the PTO Donation Program and eligibility requirements
EMPLOYEE SIGNATURE
DATE SUBMITTED

ONCE SUBMITTED TO THE SUPERVISOR, THIS SELL-BACK REQUEST IS CONSIDERED
BINDING AND CANNOT BE RESCINDED.

THE FULL NUMBER OF REQUESTED HOURS CAN NOT BE SOLD BACK IF THIS WOULD
CAUSE THE PTO BALANCE TO DROP BELOW REQUIRED BALANCE OR EXCEED
MAXIMUM ALLOWANCE TO BE SOLD BACK.


Do not include February accrual in the year of payout when determining the amount of
PTO hours allowable for the Sell Back.
NOTE TO SUPERVISORS: THIS FORM IS TO BE KEPT IN THE DEPARTMENT IN A
SECURE FILE. NO NEED TO SEND THE PTO SELL-BACK FORM TO UMHS PAYROLL
OFFICE UNLESS MNA CONTRACT MEMBER IS DONATING HOURS TO THE PTO
DONATION PROGRAM; in that event please send a copy faxed to 734-615-5822.
Updated 5-20-14