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

Part II - Application

1st period of leave

2nd period of leave

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.


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

Part IV - Approval

Once completed, provide employee with a photocopy

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

Date modified: