HTML version of the form: Application For Leave With Income Averaging

Protected when completed

Information on this form is used to assess requests for Leave with Income Averaging in accordance with approved policies. It is protected by the provisions of the Privacy Act and should be stored in standard employee bank PSE 901.

Part I - Employee Data

• Surname (Print):
• Given name / Initials:
• Personal Record Identifier:
• Department:
• Branch / Division / Section:
• Address:

Part II - Application

1st period of leave

• From:
• To:
• Duration:

2nd period of leave

• From:
• To:
• Duration:

I request a leave arrangement in accordance with the Leave with Income Averaging Policy.

I agree not to work for the federal Public Service during the above period(s) of leave.

Signature:

• Date
  • Day:
  • Month:
  • Year:

Part III - Estimated Salary (to be completed by Compensation Unit)

• Current Annual Salary and Allowances:
• Bi-weekly amount:
• Deductions:
• Net Take Home (approximate):

• Less leave without pay:
• Bi-weekly amount:
• There will be some adjustments in respect of certain statutory deductions such as Income Tax, CPP/QPP & UI and you may be able to adjust some voluntary deductions such as CSB and CO-OP.

• Reduced Annual Salary and Allowances:
• Bi-weekly amount:
• Deductions Total (Unadjusted):
• Take Home (Approximate):

Part IV - Approval

• Leave Arrangement Approved
  • 1st period of leave
    • From:
    • To:
  • 2nd period of leave
    • From:
    • To:
  • Duration of leave arrangement (12 month averaging period)
    • From:
    • To:
  • I certify that the employee meets the eligibility criteria
• Leave Arrangement Not Approved
  • for the following reasons:

• Responsibility Centre Manager (print name):
• Responsibility Centre Manager (signature):
• Date
  • Day:
  • Month:
  • Year:

Once completed, provide employee with a photocopy

TBS/SCT 325-10E (Rev. 1999-05-18)