VOLUNTARY LEAVE TIME

REQUEST FORM FLSA NON-EXEMPT

FY 2011
Complete, Sign and Submit to Your Supervisor
You may submit one (1) request for up to 96 hours of Voluntary Leave Time Off (VLT) to be taken
on specific dates (Option 1) and/or intermittently (Option 2), during a Fiscal Year (July 1 to June
30). All VLT must be taken between July 1, 2010 and June 30, 2011.
The Personnel Services Department must receive an approved request no later than 5:00 p.m. on
June 15th of the preceding fiscal year. VLT cannot be taken before July 1st.
Employee Name _____________________________________ Employee ID #_____________
(Type or Print Full Name)

Job Title ____________________________________ Department ______________________

Work Phone _________________________________

Option 1: I request to take VLT as follows:

Date: __________________ From ___________ to ___________ = ___________ # of hours
Date: __________________ From ___________ to ___________ = ___________ # of hours
AND / OR

Option 2: I request _________________ hours of VLT to be taken intermittently, and

understand that the specific dates to take this VLT must be approved by my supervisor.

TOTAL VLT HOURS REQUESTED (cannot exceed 96 hours)

IMPORTANT DISCLOSURE. PLEASE READ CAREFULLY BEFORE SIGNING: My signature below
indicates I understand and agree to the following conditions: 1) I may decline the program if the appointing
authority reduces the number of hours; 2) Once my department director has approved this request and City
of Fresno Payroll has processed it, the number of requested and approved hours is irrevocable unless I go
on an extended, approved medical leave of absence during the Fiscal Year; 3) A deduction to cover my
approved VLT hours will be made from my bi-weekly paycheck over 26 pay periods in the Fiscal Year; 4) If
my pay increases or decreases after I have taken some or all of my VLT hours, the payroll deduction will
continue at my new rate of pay beginning the pay period in which the change is effective; 5) I am
responsible for taking my approved VLT hours by June 30 of the Fiscal Year and I will forfeit any VLT hours
not taken by then; 6) If I separate from City service prior to using and/or paying back my VLT hours, my final
paycheck will be adjusted accordingly; and, 7) If I separate from City service prior to using and/or paying
back my VLT hours and my final paycheck is insufficient to cover the cost of the time, I will work out a
repayment schedule with the City.

_______________________________________
Employee Signature

Approved

Not Approved

Supervisor Signature
Original to Personnel Services
One Copy to Employee
One Copy for Department Records

Date

___________________________________
Date

Approved

Not Approved

Appointing Authority Signature

Date