REQUEST FOR DONATED LEAVE

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To receive donated leave, you must meet the following conditions:

1) Be employed in a permanent position for at least one year.

2) Be eligible for accumulation of leave under South Dakota Law, Chapter 3-6.

3) Be certified by a physician as:

   a) terminally ill and unable to return to work; or

   b) suffering from a life threatening illness or injury which prevents you from working for at least 90 consecutive days.

4) Have applied for any other public disability programs you may be eligible for.

5) Have exhausted all sick and annual leave benefits.

Name:  
Social Security Number:  
Agency:  
Public Benefits Applied for: