Fillable Printable Orange County Pay Period Affidavit
Fillable Printable Orange County Pay Period Affidavit
Orange County Pay Period Affidavit
Orange County Pay Period Adavit
Department:
to 1/12/1900
Employee #: Employee Name:
Date Vacaon Sick Leave FMLA (S/V/L) Parental Catastrophic Bereavement Military Other
12/30/1899
12/31/1899
1/1/1900
1/2/1900
1/3/1900
1/4/1900
1/5/1900
1/6/1900
1/7/1900
1/8/1900
1/9/1900
1/10/1900
1/11/1900
1/12/1900
Totals
0 0 0 0 0 0 0 0 0
Employee Signature:___________________________________________________________________________
Ocial/Department Head Approval/Disapproval:
_______
_______ I have read the foregoing applicaon/adavit and have not granted the me o as requested, for the following reason(s):
_____________________________________________________________________________________________
OFFICIAL / DEPT. HEAD SIGNATURE:_______________________________________________________________
NOTE: A physician's cercaon or note shall be required for any sick leave absence exceeding three (3) days at one me.
Court/Jury/Wi
tness
Employee Cer#caon:
!
I have read the foregoing applicaon/adavit and have granted the me o, as requested, in conformity with all Orange
county policies and procedures governing the same.
_____________________________________________________________________________________________
"!#$$$$$$$$
