STATE OF CALIFORNIA

CATASTROPfUC~
CDC 869 (11/88) PLEASE PART
DONOR

BANKDONATIONAUTHORUATION

PRINT OR TYPE A - DONATION

TO COMPLETE

DEPARTMENT OF CORRECTIONS DISTRIBUTION: ORJG!NAL -RECIPIENT'S PERSONNEL OFFICE GREEN- DONOR PIO SECOND NOTICE CANARY - DONOR SECOND NOTICE PINK - DONOR PIO FIRST NOTICE GOLDENROD - DONOR FIRST NOTICE

[NFORMATION IN
ALL COPIES TO YOUR PERSONNEL OFFICE DO NOR INFORMATION

PART A . SUBMIT

I
RECIPIENT INFORMATION RECIPIENT'S FULL NAME

DONOR'S

FULL NAME

SOCIAL SECURITY

NUMBER

POSITION

NUMBER

BARGAINING

UNIT

POSITION

NUMBER

OR CLASSIFICATION

BARGAINING

UNIT

STATE

AGENCY

I
CRED ITS DONATED
ANNUAL LEAVE

WORK

LOCATION

STATE

AGENCY

I
DONATION

WORK

LOCATION

LEAVE
VACATION

(REFER

TO THE DONOR'S
PERSONAL HOLIDAY

CONTACT

FOR MINIMUM

INCREMENTS):
OTHER (SPECIFY)

HOLIDA Y CREDIT

CTO

I certify that I have suffic ient leave credits currently of this donation and my p ersonal leave usage for the automatic establishment an d collection of an accounts amount will be automatic a lIy deducted from my next
DONOR'S SIGNATURE

I understand that this donation is irrevocable. available to make this donation. If the combination pay period from which these credits are deducted exceeds my available credits, I authorize the receivable based on the number of leave credits overused. I understand that the full net dollar available pay warrant(s) until the overpayment is collected in full.

CLASSIFICATION

P;ONE

NU~ER

DATE

YOUR NAME WILL BE IDIENTIFIED AS A DONOR UPON REQUEST OF THE RECIPIENT UNLESS YOU CHECK THE BOX REQUESTING ANONYMITY.

I REQUEST

ANONYMITY.
DA TE RECEIVED

PART

8 - DONOR'S
PART B. RETAIN

PE RSONNEL
NK PINK COPY.

OFFICE
COPY TO DONOR. FORWARD REMAINING COPIES TO RECIPIENT'S PERSONNEL OFFICE.

COMPLETE

GIVE GOLDENROD

WAS THE ABOVE

DON ATION

DEDUCTED

FROM

THE DONOR'S

LEAVE

BALANCE(S)?
PAY PERJOD(S). TYPE/HOURS DEDUCTED

D D D
SIGNATURE

YES - ALL

leave c redit(s) donated were deducted from the donor's balances

during the Ie rve creditis) donated were deducted from the donor's balances during t ae
YES - PARTIAL PA Y PERJOD(S).

The following
NO -

were NOT deducted.

MAXIMUM ALLOWED LEAVE

TYPEIHOURS

NOT DEDUCTED

Leave credit( s) donated were NOT accepted because

BY UNIT CONTRACT CREDITS A VAILABLE

ALREADY

DONATED

INSUFFICIENT

OTHER (SPECIFy) PHONE NUMBER DATE

CLASSIFICATION

) DATE RECEIVED

PART C - RECIPIENT'S
COMPLETEPARTC. RETAINO

PERSONNEL
)RlGINAL.

OFFICE
AND GREEN COPIES TO DONOR'S PERSONNEL OFFICE.

SEND CANARY

WAS THE ABOVE

DONA TION USED BY THE RECIPIENT? leave c dit( s) donated were used during the
PAY PERJOD(S).

D D D
SIGNATURE

YES - ALL

YES-PARTIAL

leave credit(s) donated were used during the e were NOT used and are hereby returned to the donor.

PAY

PERIOD(S).

The following

TVPE/HOURS

RETURNED

NO - Leave credlites) donated were NOT needed and are hereby returned to the donor.

1,",,,mCATIo,

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