Doe Ohr 300 001 Form PDF Details

Doe Ohr 300 001 Form is a form used to request an exemption from required minimum distributions (RMD) during the year. The form can be used by individuals who are 70½ or older and have total assets that don't exceed $100,000. This form must be filed with the Internal Revenue Service by April 1 of the year following the year for which the exemption is requested. For more information, consult your tax adviser.

QuestionAnswer
Form NameDoe Ohr 300 001 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdoe ohr, doe 300 hawaii, hawaii ohr leave, leave absence certificated

Form Preview Example

APPLICATION FOR LEAVE OF

ABSENCE CERTIFICATED

SCHOOL-LEVEL EMPLOYEES

DOE OHR 300-001

Last Revised: 01/01/2011

Former DOE Form(s): 400, 400a, 400a.1, 400F

DEPARTMENT OF EDUCATION

Ofice of Human Resources Records and Transactions Section, Certificated

P.O. Box 2360 Honolulu, HI 96804

I. EMPLOYEE INFORMATION

 

 

 

Name: _____________________________________________________________

Last 4 digits of SSN: _____________________

Last

First

M.I.

 

Address: _________________________________________

City: _____________________ State: _______ Zip: ______________

Tel#: ________________________

Position: _________________________

School/Office: ______________________________

School or Sub-Division Code: _ _ _

Leave Code: _ _ _

Bargaining Unit Code: _ _

II. LEAVE REQUEST (Complete appropriate subsection below.)

Family 1

 

Military 4

 

Political 5

 

Other: __________________

 

 

 

 

 

 

Funeral 2

 

 

Personal

 

Sick 3

 

 

 

 

 

 

 

Health, LWOP 3

 

 

Personnel Development

 

Vacation

 

 

 

 

 

 

 

1Complete and attach Federal FormWH-380F or WH-380E(Sde).

3Complete Licensed Physician's Statement by completing Section IV at bottom of this form for Health leave or if Sick leave for more than five (5) consecutive days or submit a signed doctor's note verifying current health condition. Approval for sick leave is subject to the availability of accumulated sick leave.

2Provide relationship to deceased and address if out of state in #2 below.

4Attach a copy of your military orders with this form (copy) to OHR, Records and Transactions Section, Certificated.

5Attach a separate letter justifying political appointment.

I hereby request the following type of leave:

 

 

 

Leave with Pay

 

 

Leave without Pay for the calendar period below:

From: _______________________

To: _______________________

_________________

MM/DD/YYYY

 

 

MM/DD/YYYY

# of working days

1. Is this an extended leave?

 

Yes

 

 

 

No

 

 

 

 

 

 

2.Provide any additional explanation for leave request (attach a separate sheet if necessary):

________________________________________________________________________________________________________

Employee Signature: _______________________________________________________ Date: _______________________

MM/DD/YYYY

III. LEAVE APPROVAL

For sick, vacation, and personal leave, Principal/Immediate Supervisor approval required.

For family, military, personnel development, and political leave,both Principal/Immediate Supervisorand PRO/CAS approval required.

Approved

Principal/Immediate

 

 

 

Not Approved Supervisor Signature: __________________________________________

Date: _________________

 

 

MM/DD/YYYY

Approved

 

 

Not Approved PRO/CAS Signature: ________________________________________

Date: _______________

 

MM/DD/YYYY

IV. LICENSED PHYSICIAN'S STATEMENT

(To be completed ONLY for HEALTH LEAVE or if SICK LEAVE is for more than five (5) consecutive work days)

I certify that _________________________________ is under my care for health reasons and is not physically able to perform

his/her normal work duties from _______________________ to ______________________.

MM/DD/YYYYMM/DD/YYYY

Licensed Physician Signature: ________________________________________

Date: _______________________

 

MM/DD/YYYY

Name of Licensed Physician (Print): __________________________________

Type of Practice: ___________________________

Address: __________________________________________________________

Tel#: ____________________________________

Distribution: Leave with Pay (Teachers): 1. Original - School; 2. Copy 1 - Employee; 3. Copy 2 - PRO (if leave exceeds one month) / Leave With Pay (EOs): 1.

Original - School; 2. Copy 1 - Employee / Leave Without Pay and Military Leave With Pay: 1. Original - OHR, Records and Transactions Section, Certificated; 2. Copy 1 - Employee; 3. Copy 2 - School; 4. Copy 3 - PRO; 5. Copy 4 - Payroll Office, Leave Accounting Section

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