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PTO Donation Form

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PTO DONATION APPLICATION FORM

Benefit Operations – April 1, 2014

Banner Health recognizes that you may encounter unexpected personal emergencies during your employment. To accommodate these situations, paid and unpaid leaves of absence are provided. In addition, in certain circumstances, as governed by IRS regulations, your co-workers may voluntarily transfer some of their accrued Paid Time Off (PTO) to you. Eligible employees must go a minimum of one shift unpaid prior to being eligible to receive donated PTO. PTO donations are governed by IRS regulations which state that in order to qualify for PTO Donations you must exhaust PTO, Short Term Disability (STD), or Workers’ Compensation payments. You must contact Cigna regarding your leave. Doctor’s certification may be required.

Based on IRS regulations, you may be eligible to receive PTO Donations if:

  • You are eligible to accrue PTO hours under the Banner Health PTO plan
  • You go a minimum of one shift unpaid
  • You or your immediate family member* experiences a medical emergency or other medical condition requiring time away from work
  • You are approved for a medically related FML (for own health condition or to be a primary caregiver for an immediate family member*)
  • You are not eligible for a medically related FML, but can provide doctor certification to support the need for absence from work
  • You do not have enough PTO to accommodate Short Term Disability (STD) seven-day waiting period (PTO Donations can be used for the seven-day waiting period for STD, but the IRS does not allow their use to supplement 60% STD pay)

Based on IRS regulations, you are not eligible to receive PTO Donations if:

  • You are not eligible to accrue PTO hours under the Banner Health PTO plan
  • You are receiving STD pay (PTO Donations cannot be used to supplement 60% STD pay)
  • You are eligible for Worker’s Compensation, Bereavement leave, STD, or have sufficient PTO to cover your absence
  • You are not able to provide medical certification related to your absence
  • You are caring for an individual that is not defined as an immediate family member*

*Immediate Family member is defined as spouse, child (includes step-children and children placed for adoption), parent, grandparent or spouse’s parent or grandparent. Immediate family member may also include domestic partner, as long as the domestic partner meets the criteria to be covered by the Banner Benefits Plans, and the domestic partner’s children, as long as the domestic partner can claim them as tax dependents.

How to apply to receive PTO Donations:

  • Prior to applying for PTO Donations, you must contact Cigna regarding your leave. Doctor’s certification may be required. For contact information, visit the Leaves of Absence page on www.BannerBenefits.com.
  • Once you have received a determination from Cigna regarding your leave request, if you are eligible per IRS regulations, you may apply for PTO Donations using one of the following methods:
    • Complete the PTO Donation Application form in the Request Center located on Banner Health’s employee website
    • Complete this PTO Donation Application Form and email it to BHBenefitOperations@BannerHealth.com or fax it to (970) 350-6624
    • Call the Benefit Operations department at (970) 350-6295 to submit a request with a Benefit Information Specialist

Benefit Operations – April 1, 2014

Employee Name (please print) Employee ID (6 digit badge ID)

Name of Person Completing this Form (if other than Employee)

Home Address City

State Zip Code Daytime Phone Number

I typically work hrs. per pay period (2weeks) and hours per day (1shift)

Describe the Medical Emergency in the box below.

Beginning Date of Absence Anticipated Date of Return

By my signature below, or that of my authorized representative, the information supplied above can be used for the approval of this application and the communication of my need to other Banner Health employees. Substantiation of the Medical Emergency may be required.

Signature of Employee or Authorized Representative

Date

Initial if Completing Form Electronically

Date

Please complete, sign, date and return this form to Benefit Operations

Fax (970)350-6624 or email BHBenefitOperations@bannerhealth.com

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What the PTO Donation Form Is and when it's used

A PTO Donation Form documents an employee's voluntary transfer of accrued paid time off to another eligible employee, often under a workplace catastrophic leave or hardship program. The form typically records donor and recipient identities, the amount of time or hours donated, effective dates, any payroll adjustments, and managerial approvals. Employers use the completed form to update timekeeping, process payroll changes, and maintain an audit trail for compliance with internal leave policies and applicable state or federal wage laws.

Why a clear PTO Donation Form matters

A well-structured PTO Donation Form ensures donor intent, protects payroll accuracy, documents managerial approval, and creates an auditable record that supports compliance with internal policy and applicable labor and tax rules.

Why a clear PTO Donation Form matters

Who completes and approves PTO donation requests

Ensure each role signs or e-signs the form to document consent and to produce a complete audit trail for payroll and recordkeeping.

  • Donor employee — completes donation details and certifies voluntary intent.
  • Recipient employee — acknowledges receipt and consent to accept donated time.
  • HR / Payroll / Manager — verifies eligibility, approves donation, and updates time records.

Core sections to include on a professional PTO Donation Form

A complete form groups identity, donation details, approvals, payroll instructions, supporting documentation, and an audit trail so all parties and systems can process the transfer consistently.

Donor identity

Full legal name, employee ID, department, and contact information to match payroll records.

Recipient identity

Full legal name, employee ID, department, and confirmation of eligibility under policy.

Donation specifics

Number of hours/days, type of leave (vacation, personal), effective date, and remaining balance after donation.

Approvals

Manager and HR sign-off fields with dates and optional attestation of policy compliance.

Payroll instructions

Fields for payroll code updates, effective pay period, and any taxable treatment notes.

Audit trail

Space for signer authentication method, timestamps, and a unique form ID for recordkeeping.

Required information and short-field checklist

Donor name: Full name
Donor ID: Employee number
Recipient name: Full name
Recipient ID: Employee number
Hours donated: Hours or days
Effective date: MM/DD/YYYY

Step-by-step: completing the PTO Donation Form

Follow these steps in order to ensure valid authorization and correct payroll posting.

  • 01
    Prepare form: Enter donor and recipient details accurately.
  • 02
    Specify donation: Record exact hours or days and effective date.
  • 03
    Get approvals: Obtain manager and HR signatures or eSignatures.
  • 04
    Submit to payroll: Send completed form to payroll for posting and record retention.

Typical online workflow settings for eSubmission

Configure routing, authentication, and field behavior so the form moves automatically from employee to manager to payroll.

Field Configuration
Signing order Donor → Manager → HR → Payroll
Authentication Email + SMS code for manager and HR
Conditional fields Show payroll code only after manager approval
Notifications Auto-email completed PDF to donor, recipient, and payroll

How to distribute and accept the form electronically

Use integrations with payroll and HR systems to automate posting and to keep a single authoritative record.

  • Email link: Send a secure signing link to signers' email addresses.
  • Intranet/Kiosk: Host a form on internal portals or kiosk stations for on-site signing.
  • API integrations: Embed form in HRIS or payroll systems using API connections.

Typical processing flow after submission

The form follows a linear review and posting workflow; automation reduces manual entry and errors.

  • Submit: Employee completes and signs the form.
  • Review: Manager and HR verify eligibility and approve.
  • Post: Payroll applies donation and adjusts balances.
  • Archive: Completed form stored in HR recordkeeping system.

Timelines and processing expectations

Set internal deadlines so donations post to the correct pay period and accrual balances remain accurate.

Submission window:

By payroll cutoff date

Manager review:

Within 3 business days

HR approval:

Within 5 business days

Payroll posting:

Next payroll cycle after approval

Record retention:

Retain per retention schedule

Common mistakes when preparing a PTO Donation Form

  • Incomplete donor or recipient identifiers that prevent matching in payroll systems and cause posting errors or rejected entries.
  • Failing to confirm recipient eligibility under the employer's policy, which can lead to retroactive reversals and employee disputes.
  • Missing or unsigned manager or HR approvals, voiding the transfer under internal controls and creating audit exceptions.
  • Entering the wrong effective date or pay period, resulting in misapplied hours, accrual inconsistencies, and payroll corrections.

Risks and compliance consequences of incorrect forms

Payroll misposting: Can require costly corrections
Tax withholding: May trigger improper withholdings
Policy violations: May create internal compliance issues
Employee disputes: Risk of grievance or claim
Audit findings: Weak controls may cause exceptions
Recordkeeping gaps: May violate retention rules

Electronic signature types and what they mean for this form

Understand differences between general electronic signatures and cryptographic digital signatures to select appropriate authentication.

Criteria Electronic Signature Digital Signature
Definition broad legal method pki-based cryptographic
Legal acceptance yes (esign/ueta) yes (esign/ueta)
Non-repudiation audit trail evidence stronger cryptographic proof
Typical use hr forms high-assurance or regulated records

eSignature vendor comparison for PTO Donation Form workflows

Compare starting price and common capability indicators; signNow is listed first per vendor ordering rules and all vendor details should be verified with each provider.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (plan) Varies by plan Varies by plan Varies by plan Varies by plan
Audit Trail Yes Yes Yes Yes Yes
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions about PTO Donation Forms

Answers to common implementation, legal, and processing questions for HR and payroll teams.


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