SETTL EM ENT AGREEMENT AND RELEASE

THISAGREEM ENT is made by and betwee'i theTeed'Ier Retirement ?rstem of Texas (TRS) acting
through its undesigned dgnated repraentative and Tina Genes for themselves and on behdf
of their raaective mgns, heirs, represe'itaiyes, and age'rts, subject to the following terms and
conditions

In consideration of the terms and conditions and mutud agreemens stated herein, the pati? agree as
fol lows:



The patties agree that, by erecution of this agreement, Tina Carries hereby tenders her
resignation from errploymeit with TRS, such resignation to beccmeeffectivess of the close
of busim on November 1, 2014.

For the consideraion of submitting her resignation and other valuable consideration,
including the contained herein, TRS hereby sgrea to continue to employ Tina
Canes under the terms and conditions set forth herein, from April 29, 2014 through the
effective date of resignation. TRS will make all my and required deductions
including but not limited to, a'nomts forthe TRS federd income tax, and
sooid security tax from this amount in compliance with anplicdale laws, mwell any
other types of werein effect with regard to Tina Canes? satay from TRS for
the month of April 2014.

The parties arse the Tina Canes will remain on payroll and beginning April 29, will be
placed'on leave with pay by the Execlniye Director until the close-of business on the
effective detect rgnaion, with Tina Carla receiving her current salary (ladeductions in
compliance with applicdaie laws and this agreement) and benefits unless specifically set out
differently herein. In accordance with state law 3101 TRS policy, Tina Canes will be
compen?led for any unused, accrued vacation lace, but will not amue additions! leave of
any type after April 29, 2014.

The pertiafurther areethat at dl times Tina Canes is entitled to seek and to accept other
enployment, and that the acceptance of other employment not abeteor cancel her right
to remain on the payroll of TRS through Noye'nber 1, 2014. In the eyeit that her
is with another state employer, TRS agrees to repraent, when allowed and in
compliance with state law and TRS policy, that Tina Canes continued TRS enploymeit
benefits TRS and that there is no mnflict with the position she holds with TRS and to make
other reesonablee?fort to ensure continued payment through the date of red gnation.

The parties ag'eetha?. at all timeswhilesheise'rployed by TRS, Tina Carneswill adhereto
all employee policies in a manner consistent with the expectations held by TRS for
enployees

The parties agree that after with TRS ends on Noye'nbe' 1, 2014, TRS will
provide a re?erence as outlined in the TRS re?eeme policy. Speci?cally, unla otherwise
required by law, without written authorization from the employee, TRS releases only

information about a wrrent or fonner m?ployees employment that is subject to disclosire
uncle'the Publielnfca'rretionA'ct;

The patia agree that after with TRS ends on November 1, 2014, Tina Canes
will conduct herself in acoordmce with all rules governing an attorney licensed in Texas
Specifically. but not limited to, regacing confidential information, as defined by the Texas
Disciplinary Rulesof Prof?iond Conduct, Tina Carneswill adheretothefollowing:
A- lawyer shall not knowingly:
(1) Revesl confidth information of a client or aformer client to:
a person that the client has instructed is not to receive the
information; or
(ii) myone else, other than the client, the client?s rearesmtatives. or
the members, associates, or enployeesof the lawyer?s law firm.
(2) Use oonfideatid information of a client to the-disadvantage of the client
unless the client consents after consultations
(3) Use confidential information of a former client to the disadvantage of the
former client after the reprasntation is oonduded unl?theforme' client
consents a?ter ocr'rsultstion or the confidential information has become
gene'dly known.
(4) Use privileged information of a dimt for ?1eadvmtegeof the lawyer or
of athird person, unl?theclient consents after consultation.

In consideration of continued employment stated in Item 2 and other good and valuable
oonsiderstion, the srffidency of whid1 is hereby acknowledged, Tina Calm hereby waives
relates. acquits, indennifies, holds harml? and forever discharga TRS, the trust ?nd, its
past, present, and future trustees, erployees, represe'Itatives md age-its, in their officid and
incividust cmecitia ?'om at obligations demuzls, cia'ms, expel-15, of action.
damages, and liability of whatever nature. whether in tort or in contract, in equity, at
oomnon law, or by virtue of my civil rights or other federal or state constitution, lav,
regulation, or mletha was raised by Ms Carla or could have been raised by her and arising
from or regarding her employment with TRS. Ms Canes agres not to sue TRS or
the fund, its past. present, and future tmstees, employees, representatives, or agents in their
official or individual cmecities related to her- ei-?nploynm with to psrticipste, unless
required by law, in my federd or state judicial or my fede'al or state administrative
proceacing against TRS or its trustees, emoyees or mentsin their official
or individuat capacities related to her employment with TRS.

The parties hereto expr?ly acknowledge and mree that nothing in this Agree'ne'rt is meant
to we've. relemor ettinguish my right on thepm of either paty heretoto file a lewsJit to
enforoethisAgreemem md to seek to recover my and ail dm'isgescsussd by my brea?t of
this Agreement. Howerer, prior to and as a condition precedent to the institution of my
such legal proceeding, the parties hereto agree to attempt to raolve my dispute arising from
or with regard to the interpretation or perfonnmoe of this Agree-hen through non-bi riding
mediation presided over by a mediator n'utuelly aoomtdole to the parties AS NOTED
ABOVE, THIS AGREEMENT TO ENGAGE IN NDING MEDIATION IS
INTENDED BY THE PARTIES TO THI SAGREEMENT TO BE AND IS I FACT A
CONDITION PRECEDENT TO THE FILING OF ANY CLAIM OR DISPUTE
INVOLVING THE INTERPRETATION OR PERFORMANCE OF THIS
AGREEMENT.

10. In case any provision in this Agreement snail be invalid, iliegd or unenforceable, the
vdidity, legality and of the ran-airing p'wiscns shall not in any way be
satis?ed or impaired thereby and such provision shall beine?fectiveonly totheettent of such
invsiicity, illegdity or Hmeirer, if inclusion of any term of this
Agreement is proribited cr voided by applicable law or regulation, the Agreement she? be
red without such term and be deemed to have been written and entered into without
suchterm.

11. Tina Canes further agrees in ccnsidestion of continued ermloyment stated in Item 2 and
other good and vaiusble consideaicn that shewill not apply for re-employment with TRS at
any time in thefuture.

12. The paties sgre that this agreement does not constitute an admia?on of liability by either
side, dl liability being e<presdy denied. Rather, it is entered into in order that the patiesto
this agreement may findty resolve their without the buden and atpaise of
further admi nistrative proceedings or litigation.

13. This Agreement constitutes the entire understaiding and greenent bawesn the parties with
ranect to the subject matter identified in this document. There are no 
areernents, aTa'igemmts or understandings. 0rd or written. between or amng the parties
reiating to the subject matter of this Agreement which are not fully in this
dowrnent. This Agreeme'rt may not be mortified or amended except by written qeqnent
etecuted by thepa'ties hereto.

14. Ms. Cernes sgrea to return all TRS property, induding. but not limited to, dowments.

computers, con'pute? equipmmt, batge and keys in her possession and further 59% to
retrieve my TRS property that she has givei or entrusted to a third party and return that

property to TRS.

15. This Agreement is effective imrned aterr upon execution by the parties The patia intend
for thisAgreement to befully compliant with Tera law.

16. To ensure interests are protected, it is stroneg recommend the: Tins Canes have legal
review priortc signature.

IN WITNESS THEREOF. all of the parties hereto l'isve ecewted this agreement in multiplecriginais
to beeffectivefrom and after the 28m dayr of April 2014.

I .

A  
IL,  214? Akr-  a"
TinaCarnes Date


De

      

Brian K. Gut rie, ecutive Director.
Teacha' Retirement System of Tetas
For the Teacher Retirement System of Term

TEACHER RETIREMENT SYSTEM OF TEXAS

1000 Red River Street, Austin, Texas 73701-2698
Telephone (512) 397-6400 or 300-223-8778

16
Rev. 9-97

REQUEST FOR APPROVAL OF LEAVE

(NOTE: Not for use in requesting Sick Leave Pool)

 

I. Employee Name: {Please Print)

Tina Carnes

Social Security Number

Department:

Legal Services

 

 

II. I request leave as speci?ed below:

DATE FROM: 06f13714 mm
Time

DATE TO: 10f27?4

mm
mumon

Time

NO. OF HOURS TYPE EM
CODE

 

 

Ill. Types ofleaves and codes:

 

SL - Sick leave of more than 3 consecutive
days (Sec #1 3r. #2 below}

ES - Extended sick leave (Sec #3 below}

EM - Emergency leave {See instructions on back]

FORWARD TO ACCOUNTING IF FOLLOWING LEAVE REQUESTED:

ML - Military leave (Attach a copy of orders;
15 work days maximum per federal FY)

J5 - Jury Service {Attach a copy of summons)

0 - Other
(See other available leave on back)

RETAIN IN IF
FOLLOWING LEAVE REQUESTED:

SL - Sick leave of 3 or less consecutive days

VC - 1visitation leave
CT - Compensatory time taken

OT - Overtime taken (FLSA non-exempt
employee only)

 

I. if absence was due to illness of a member of your immediate family {see de?nition on back), does hefshe live in your household? Yes 
No It' ND is checked, use of sick leave is limited to the time necessary to provide carefassistance to employee?s spouse, child other
than a minor child or parent who needs care and assistance as a direct result of a documented medical condition. Sick leave was used for
my child spouse or parent El, not living in my household.

2. If you are absent more than three consecutive days due to illness, attach medical certi?cation include a written statement below which
is acceptable to your manager concerning your illness, and contact the FMLA Coordinator.

3. Ifyou are requesting extended sick leave, attach medical certi?cation a written justi?cation below which is acceptable to your manager
concerning your illness and contact the FMLA Coordinator.

 

 

If requesting extended sick leave: have you used sick leave pool for this illness? No Yes 

IV. StatementtExplanation of circumstances (required for extended sick leave, emergency leave. or sick leave of more than 3 consecutive
days) or attach medical certi?cation.

How many hours?

 

 

 

 

 

V. I hereby certify that all information is true and correct.

 

Employee Signature

 

Date

 

 

VI. Approvals

Team LeadeniSupervisonr

 

EIApprovcd as requested El Approved for hours Disapproved Manager Signature: Date:
Division Directorr'Chief Of?cer!
UApproved as requested Approved for hours El Disapprovcd Executive Director Signature: Date:

 

 

 

VII. Approval for Extended Sick Leave and Emergency Leave

EApproved as requested Emfor
Executive Director Signature: 

hour. Disapproved
ally?

 



 

See instructions and information on back.

 

Teacher Retirement System - Ar1ene B. Caba11ero, CPP

GD

 

00323

 



 



 

BALANCE DETAIL BY LEAVE 

00323 EMPLOYEE SSH-D

CARNES, TINA MARIE
LEAVE E0 - EMERG OTHER CURRENT 360:00-

START DATE ACTIVITY ST HDURs ENTRY DATE REASN 0PID
06/16/2014 TAKEN 1:00 10/26/2015 AGU698
06/16/2014 M0 TAKEN 16:00 10/26/2015 AGU693
06/09/2014 M0 TAKEN 40:00 10/26/2015 AGU693
06/02/2014 M0 TAKEN 40:00 10/26/2015 AGU698
05/22/2014 TU TAKEN 32:00 10/26/2015 AGU698
05/19/2014 MU TAKEN 40:00 10/26/2015 AGU698
05/12/2014 ND TAKEN 40:00 10/26/2015 AGU698
05/05/2014 M0 TAKEN 40:00 10/26/2015 AGU698
05/01/2014 TH TAKEN 16:00 10/26/2015 AGU698

04/29/2014 TU TAKEN 16:00 10/26/2015 AGU698



 

 

NDn-RespDane

 

 

ARE

Date: 5/25/2016 Time: 3:59:26 PM Page: 1

FOR FY 2015

ON HN9U3

05/25/16 15:59:11 1 M3LL PARJ 

TEACHER RETIREMENT SYSTEM OF TEXAS TRSI lo
[000 Red River Street, Austin, Texas Twill-2698 9-9?
Telephone {512) 3916400 or 800-223-37?3

REQUEST FOR APPROVAL OF LEAVE

Not for use in requesting Sick Leave Pool)
I. Employee Name: (Please Print) Social Security Number Department: 

Tina Carries  ??21?i5520 Legal 

 

 

 


II. I request leave as speci?ed below: WV
DATE FROM: 30l914 DATE TO: [1325 I4 NO. OF HOURS it} TYPE 5  
Time MM Time 

 

 

Types ofleaves and codes:

 

FORWARD TO ACCOUNTING IF FOLLOWING LEAVE REQUESTED: RETAIN DIWDEPT IF
FOLLOWING LEAVE REQUESTED:
SL - Sick leave ot?more than 3 consecutive ML - Military leave (Attach a copy of orders; SL - Sick leave ot?3 or less consecttlivc days
days [See #l #2 below] 15 work days maximum per federal 
VC - lv'acation leave
ES - Extended sick leave (Sec #3 below] JS - Jury Service (Attach a copy ol?summons] CT - Compensatory time taken
EM - Emergency leave [See instructions on back] - Other Emergency [gem OT - talten non-exempt
(See other available leave on back] employee only]

 

If absence was due to illness of'a member of your immediate family (see de?nition on back}. does hetshe live in your householdchecked, use of sick leave is limited to the time necessary to provide caretassistance to employees spouse. child other
than a minor child or parent who needs care and assistance as a direct result ot?a documented medical condition Sick leave nus usctl I?m
my child  spottse El. or parent not living in my household.

2. lt?you are absent more than three consecutive days due to illness. attach medical certi?cation include a written statement hclou hiclt
is acceptable to your manager concerning your illness. and contact the FMLA Coordinator.

3. lt?you are requesting extended sick leave, attach medical certi?cation a written justification below which is acceptable to your manager
concerning vour illness and contact the FMLA Coordinator.

 

W. Statementr?Explauation of circumstances (required for extended sick leave. emergency leave. or sick leave of more than 3 consecutive
(lays) or attach medical certi?cation.

If requesting extended sick leave: have you used sick leave pool for this illne?ss?? No CI 1r'es Hov. many hours?? 

 

Emergency leave is being requested for the death of [The funeral and other services were he held in Itenmondville.  ?csas__

topmost-inniter 300 miles from Austin tgoogle 304? on March 20 and list. lstayctt and assisted 552.11  in closing an 5531173523 nose and
making arrangements for the storage of other personal items.

V. Wrists)? certilyat all Wade? is true and correct.
f) 
[(444.2 v% by ?nmk~ c: 41/
Myer: Signature Date I 

If??rs
VI. Approvals 0 
Team Leaden?Supervisort - ti
Cat ?in 3 3i i

mproved as requested Approved for hours [1 Disappruved Signature: 
Division DirectortChiet'Oll'icert
hours Disapprovetl Executive Director Signature: Date:

 

 

 

 

 



 

CIA proved as requested CI Approx-"ed for

 

 

1 igl/ Approval for Extended Sick Leave and Emergency Leave
A

for hours Disapproved
 v/t/tv

pproved as requested I: A pro

  
 

 

Executive Director Signature: 

 

 

 

 

See instructions and information on back.

TEACHER RETIREMENT SYSTEM OF TEXAS . TRSI 16
1000 Red River Street, Austin, Texas 73701-2698 Rev. 9-9?
Telephone (512) 39164400 or 800-223-87?3

REQUEST FOR APPROVAL OF LEAVE

(NOTE: Not for use in requesting Sick Leave Pool}

 

I. Employee Name; (Please Print) Social Security Number Department:

William R. Diel - - IT

 

 

II. I request leave as speci?ed below:

DATE FROM: Ulr?06f15 DATE TO: Ult?23r'15 NO. OF HOURS I0l:lS TYPE HO
'l'imc Time CODE

 

 

Ill. Types ofleaves and codes:

 

FORWARD TO ACCOUNTING IF FOLLOWING LEAVE REQUESTED: RETAIN IN DIVIDEPT IF
FOLLOWING LEAVE. REQUESTED:
SL - Sick leave of more than 3 consecutive Ml, - Military leave (Attach a copy oforders; SL Sick leave off: or less consecutive days
days (See if] ti: #2 below) l5 work days maximum per Federal 
- VC - 1 v?aeation leave
ES - Extended sick leave {See #3 below} .15 - Jury Service (Attach a copy of summons) CT - Compensatory time taken
EM - Emergency leave (See instructions on back} 0 - Other 01' - Overtime taken (FLSA non-exempt
{See other available leave on back) employee only)

 

l. was due to illness ol?a member ot'your immediate family (see de?nition on back), does live in your householdchecked? use ofsick leave is limited to the time necessary to provide carcfassistance to employee?s spouse, child other
than a minor child or parent who needs care and assistance as a direct result of a documented medical condition. Sick leave was used for
my child spouse or parent not living in my household. 

2. If you are absent more than three consecutive days due to illness, attach medical certi?cation include a written statement below which
is acceptable to your manager concerning your illness, and contact the FMLA Coordinator.

3. It'you are requesting extended sick leave, attach medical certi?cation and a written justi?cation below which is acceptable to your manager
concerning your illness and contact the FMLA Coordinator.

 

 

IV. of circumstances {required for extended sick leave, emergency leave, or sick leave of more than 3 consecutive
days} or attach medical certi?cation.

If requesting extended sick leave: have you used sick leave pool for this illness? No Yes How many hours?

 

 

 

 

 

V. I hereby certify that all information is true and correct.

 

 

Employee Signature Date

 

 

VI. Approvals

Team LeaderfSupervisort

 

DApprovc-d as requested El Approved for hours Disapproved Manager Signature: Date:
Division Directon'Chicf Of?cer:f
Edpproved as requested Approved for hours El Disapproved Executive Director Signature: Date:

 

 

VII. Approval for Extended Sick Leave and Emergency Leave
??/pproved as requested El Ap on

Executive Director Signature:

hour El Disapproved

        

 

 t/ 7/ 1S

 

 

See instructions and information on back.

Release and Settlement Agreement

This Release and Settlement Agreement is entered into on October 26, 2015 by Cheryl Hines ("Hines") and
the Teacher Retirement System of Texas (TRS). The parties have negotiated the terms of Hines' exit and
reached this bona fide settlement in relation to any claims that may relate thereto. The parties sign this
Agreement in exchange for the good and valuable consideration set forth herein, which absent this
Agreement, neither party is obligated to provide to the other and the adequacy of which is hereby 
acknowledged. The parties acknowledge that the terms and conditions of this Agreement have been agreed
to and that such terms are intended to be ?nal and binding.

Terms and Conditions

By the execution of this Agreement, Hines hereby tenders her voluntary resignation from her
employment with TRS, such resignation to become effective on the close of business on April 30,
2016, referred to herein as ?date of resignation." Until Hines's date of resignation, Hines will be
placed on a paid leave status with TRS, where she will continue to receive her compensation and
bene?ts at her current rate but will not be required to attend work in the office. Hines's last day
worked in the office shall be October 5, 2015.

Hines agrees that after the mutual execution of this Agreement by the parties, no further action of
herself or of TRS is required to effect her resignation from all or any employment with IRS on the
date of resignation and that her resignation is hereby accepted on behalf of TRS and is non-
rescindable by her.

TRS agrees that it will provide a neutral reference for Hines in response to any inquiry. Hines
agrees that she will direct any and all requests for references to the TRS Human Resources
Department. In response to any inquiry, TRS agrees that it will only provide dates of employment,
title, and last salary for Hines, unless otherwise required by law.

For the consideration of submitting her resignation and other valuable consideration, including the
releases contained herein, TRS hereby agrees to continue to employ Hines in a paid leave capacity
under the terms and conditions set forth herein through date of resignation and to compensate her
at her current salary and pay grade through that date. Such payments shall be paid in installments
pursuant to normally applicable payroll schedule in an amount equal to Hinesf salary payment
(reduced by applicable withholdings under federal and state law and Hines? authorized bene?t
premium contributions) for such payroll period, and each installment shall be treated as a separate
payment for purposes of Internal Revenue Code Section 409A. Benefit coverage provided to Hines
as an employee of TRS will continue at the current level and premium rates through the last day of
the month of her date of resignation for her and her 552_117;55 Hines may obtain continued
health benefit coverage after that date through CC. RA at her expense. It shall be Hines?s
responsibility to apply for COBRA continuation coverage upon receipt of required paperwork from
TRS. Any accrued, unused leave time that Hines has as of October 5, 2015 will first be deducted
prior to Hines being placed on administrative paid leave status. Hines will not accrue any leave
time after October 5, 2015. Hines shall be eligible to participate in the TRS Incentive
Compensation Plan testament to the terms and conditions of that Plan through the date of
resignation.

 

 

 

 

5. For the valuable consideration set fonh herein, Hines fully releases and discharges the

pension trust fund; andlor its past, present, and future trustees, employees, representatives, agents
and assigns, all both in their individual and in their of?cial capacities, from all claims. rights and

1

obligations arising under common law or under federal or state constitutions or laws and relating
to, arising out of or regarding any acts or events, including but not limited to acts or events related
to her employment with TRS. occurring up to the date on which this Agreement is executed. Hines
further agrees to refrain from instituting, prosecuting. pressing. or in any way aiding in the
institution or prosecution of any investigation, suit. claim, action. appeal or administrative
proceeding of any kind or character whatsoever against the pension trust fund; andfor its past,
present or future trustees. employees, representatives. agents and assigns. in eithertheir individual
or in their official capacities. In the event that on the date of the execution of this Agreement.
Hines has already initiated an investigation. suit, claim. action. appeal or administrative proceeding
of any kind or character whatsoever against the pension trust fund; andfor its past, present or
future trustees, employees. representatives. agents and assigns. in either their individual or official
capacities, Hines agrees to withdraw. dismiss. or reque5t the closure of the investigation, suit. claim.
action, appeal or administrative proceeding. It is the express and unequivocal intent of Hines to
release all claims of any kind or character whatsoever that she has or might have against the
pension trust fund; andfor its employees, agents and assigns. trustees or representatives, whether
current or former, all both in their official and in their individual capacities, arising at or before the
date on which this Agreement is executed. Notwithstanding the above release, Hines shall be
entitled to make claims and seek any health insurance benefits available to her as a former employee
of TRS and to apply for and receive a refund of her TRS member account under the terms of the
TRS pension plan and to redeem her 401(k) and 457(b) retirement accounts under the terms of the
plan and in accordance with applicable laws.

The release and waiver by Hines set out in Paragraph 5 above includes a waiver of her rights under
the Age Discrimination in Employment Act. the requirements for which are codified in 29 U.S.C.
?626(f). This waiver of rights only applies to those rights or claims arising at or before the date on
which this Agreement is executed by Hines. and those rights are know waived in exchange
for the consideration which is incorporated in the settlement terms referenced in this Agreement.
l-Iines?s execution of this Agreement acknowledges that she has been informed of her right to
consult with at attorney regarding this Agreement and the rights and claims that she is
releasing and waiving. Hines voluntarily and knowingly manifests her consent to this Agreement
through her signature on the Agreement. Hines has twenty-one (21) days within which to consider
this Agreement, and seven (7) days after signing the Agreement to revoke the Agreement. The
Agreement shall be irrevocable and binding upon Hines. her heirs and her assigns after the
expiration of the revocation period.

In the event that Hines ?les any claim. lawsuit. proceeding. or in any other manner seeks to
invalidate or breach or does breach any provision of this Agreement. including but not limited to
the provisions of paragraphs 5 and 6 of this Agreement prior to her resignation date. this Agreement
will immediately become void and Hines? employment will inunediately terminate. In the event
that any dispute arises with respect to this Agreement. the party who believes there may be a breach
shall contact the other party in writing setting forth the reason(s) for the belief and shall give the
party ten (10) business days to remedy the matter.

Hines further agrees to release and hereby fully releases and discharges the pension trust
fund; andfor its past, present. and future trustees, employees. representatives, agents and assigns,
all both in their individual and in their of?cial capacities from any and all liabilities andfor
obligations under any law, rule. regulations or practice to reimburse Hines for attorney's fees and
any and all costs in connection with the negotiation and execution of this Agreement. Hines shall
reimburse. indemnify and hold TRS harmless from any and all claims or demands for payment of
her attorney's fees and expenses arising from, or related to her employment. including the cessation
of her employment with TRS. if any.

9. The parties hereto expressly acknowledge and agree that nothing in this Agreement is meant to
waive. release or extinguish any right on the part of either party to file a lawsuit to enforce this
Agreement and to seek to recover any and all damages caused by any breach of this Agreement.
However. prior to and as a condition precedent to the institution of any such legal proceeding,
the parties agree to attempt to resolve any dispute arising from or with regard to the interpretation
or perfonnance of this Agreement through non-binding mediation presided over by a mediator
mutually acceptable to the parties. AS NOTED ABOVE, THIS AGREEMENT TO ENGAGE
IN NON-BINDING MEDIATION IS INTENDED BY THE PARTIES TO THIS
AGREEMENT TO BE AND IS IN FACT A CONDITION PRECEDENT TO THE FILING
OF ANY 0R DISPUTE INVOLVING THE INTERPRETATION OR
PERFORMANCE OF THIS AGREEMENT. Should the mediation required by this portion of
the Agreement not be successful in resolving the dispute and a lawsuit is filed seeking to enforce
this Agreement and to recover any and all damages caused by any breach of this Agreement. the
prevailing party in any such lawsuit will be entitled to recover attorney fees against the other party
to the extent authorized by law.

10. Hines warrants that this Agreement will dispose of all liability of TRS to her and to her
heirs and assigns. Hines further warrants that she has not assigned her rights or claims herein
released to any other individual. company or entity. Should any further claim be made arising out
of the claims and causes of action herein released for which TRS might be liable. Hines will
indemnify TRS. along with the pension trust fund; andfor its past. present, and future trustees.
employees. representatives. agents and assigns from all liability for such claims. including all costs.
expenses and attomeys' fees it incurs in defending such claims. Hines agrees to assume all
responsibility for. and shall indemnify and hold TRS harmless from. any and all claims. losses.
damages. liability. suits. actions. judgments. costs. taxes. interest. penalties. expenses and
attorneys? fees resulting from any liability or claim of liability due to any federal. state or local
government or agency thereof. in relation to the benefits provided to Hines by TRS.

1. Hines further agrees that she will not apply for reemployment with TRS at any time in the future.

12.. Hines agrees to return all TRS property. including. but not limited to. information. training
materials. documents, computers. computer equipment. badge. and keys in her possession and
farther agrees to retrieve any TRS property that she has given or entrusted to a third party and return
that property to TRS at the time of her resignation.

13. It is expressly understood and agreed that the terms of this Agreement are contractual and are not
merely recitals. and that the agreements contained in it and the consideration given are to resolve
all matters arising out of Hines?s employment with TRS. The parties deny liability, and have not
admitted and do not admit liability for any incident, events. actions. or omissions regarding or
arising out of Hines's employment or separation from employment with TRS. Nothing in this
Agreement shall be construed as an admission of liability. all such liability being expressly denied.
The parties to this Agreement mutually acknowledge and represent that this is a compromise in
resolution of any disputed claims or possible claims and is made solely to avoid the uncertainty.
time. and expense of administrative proceedings. andfor litigation and to facilitate a smooth
transition for both parties in the termination of the employment relationship with Hines.

14 This Agreement is intended to comply with the requirements of Section 409A of the Internal

Revenue Code of 1936. as amended. and the regulations thereunder (?Section and shall be

construed and administered in accordance with Section 409A.

15. Hines, on behalf of herself. her ?532-117?552-0 nd her representatives, agrees that the terms and

provisions of this Agreement. as well as its existence and any discussions or negotiations related to
this Agreement, constitute highly confidential information and shall not be disclosed to other
persons or entities. except: as required by applicable law or if ordered by a court of competent
jurisdiction; as necessary to Hines?s attorney. certi?ed public accountant or tax preparer for the
purpose of obtaining legal advice or ?nancial planning advicepreparing and
filing tax retums or other documents required by law: to) Hines'sr other close
or as necessary to any administrative agency to report wages paid.

The provisions of this Agreement are severable and the invalidity or unenforceability of any
provision of this Agreement shall not affect the validity or enforceability of any other provision. It
is the intention of the parties that each provision of this Agreement be construed in a manner
designed to effectuate the purposes of the provision to the maximum extent enforceable under
applicable law.

17. This Agreement shall be binding upon and shall inure to the benefit of the parties to this Agreement
and their respective heirs, successors. assigns. and legal representatives. This Agreement may be
executed in multiple counterparts. each of which is fully effective as an original, but all of which
together constitute one instrument.

18. This Agreement shall be construed without regard to the identity of the person or persons who
drafted the provisions contained in this document. Moreover. each and every provision of this
Agreement shall be construed as if each party to this Agreement participated equally in the drafting
of this document. As a result of the foregoing, any rule of construction that the document is to be
construed against the drafting parties shall not be applicable to this Agreement.

19. This Agreement constitutes the entire understanding and agreement between the parties with
respect to the subject matter identified in this document. There are no representations. agreements.
arrangements or understandings. oral or written. between or among the parties misting to this
Agreement or the subject matter of this Agreement that are not fully eXpressed in this document.
This Agreement may not be modi?ed or amended except by written agreement executed by the
parties hereto.

20. This Agreement is effective immediately upon execution by the parties.

IN WITNESS WEREOF, the parties have made and executed this Agreement on the dates stated
below.

 


Brian Guthrie date

Executive Director. Teacher Retirement System of Texas

TBS THE 116 (Special Leave Request)
Last Revised: 3-2015

 
 

I 1- Employee Section 

 

PIEase ?ll out the ?elds In Seclon 1. Print the ionn doubleeslded [the form prints double-sided by default]. Read the acknowiedgement. Sign and date the form,
and submit it to your man agar ?10 Complete Section ii. Alter your manager returns the form to you, submit it directly to the workplace accommodatiOns coordi-
nator, along with any reqmred documentation as appropriate (see Section Tip: To save the form, press 

 

a. Employee lnl'o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Name (Last, First, M.I.): Department Name: Phone:
Hines, Cheryl 
b. Leave Info c..Requlred'Documentation
r5 Requesmd: Leave 339'" Date: Leave End Date: Date Of Request: To be approved for the special leave listed below, you must submit 0450,16 workplace accommodations coordinator the appropriate documentation
as well g?tth?S form. Terese for 
. . a prop a ocumen a onw 5 severe ues. mpor'tan no
Type or Leave' requesung Emergent? Leave other ?r Other Leave' ?ease spear? a tech the documentation to this form until a ter your manager has re-
Emergency Leave - Bereavement" amicable Pool tum? the form ?3 
Em?r en? Lea - Du Sictchovc Bereavement LeaV?
9 Please submit tine of the following documents:
Emergency Leave - Hinton: Other Leave . Obituary
Death certi?cate
. Emergency Leave - Other - Newspaper clipping
- Funeral program
requesting ?Emergency Leave Other" or ?Other Leave,l please specify. I Contact information for the funeral home
I Other (please Include an explanation]
Speedy Emergency Leave - Other: Specn'y Other Leave:
*Submit an explanation with the form if either of the following is true:
You are re uesting more than 24 hours, and the service is less than
300 miles rorn our home.
0 You are request ng more than 40 hours.
.?lur'yr Leave
Please su mit a copy of the summons.
Military Leave
When available, pleasa submit a copy of the orders.
[f ti eavement Leav late the folio I Extended Sick Leave
?Tunes "9 ?350 camp ?9 also? slaubn?it dlr?c?yd?o tlhle work gig.-  
- am an ca eave Name Of Deceaseu Employee 5 t0 Deceaseu form. Forms can be obtained from the workplace accommodations coor-
dinator.
th zoo ll I SiCk Leave P001
gr ?55363: mate than es mm your me ease ?lm: em Please submit directly to the work lace accommodations coordinator in
I HR the Family and Medical Leave ct Certi?cation of Health Care Provider
Miles from Home: Location of Servrce {City and state): form and the Supplemental Medical Certi?cation term Forms can
be obtained from the workplace accommodations coordinatorEmployee Acknowledgement .?ti NJ P: i bk.- 
i acknowledge that I have reviewed the TRS Leave policy. i understand that to be eligible for leave, I must meet the Conditions de?ned In the policy.
Sign Employee Signature: Date:
here

 

You have certain rights under Chapters 552 and 359, Government Code to review, vest and correct Information we have on ?le about you.
For more Information. con?ict the workplace atlons coordinator in HR.

 

 

I 11. Manager and Chief] Director Section

 

if the employee is requesting extended sick leave or sick leave pool, please cempIete Section ll.a. Sign and date the form, and return it to the employee.

 

a. Abuse of Leave and-Corrective Action

 

 

 

 

 

 

is there decumented evidence that the employee Has the employee received a second- or third?level El
has abused leave within the past 12 months? ?0 El Yes corrective action within the past 12 months? NO Yes
a. Manager and Chiefi'Dlrector Comments, info, and Signatures
Comments:
Manager: Date:

Sign
here 

Sign
here

 

Chieh'Directo r: Date:

 

 

 

 

The Human Resources Section and Executive Administlation Section are on page 2 of this form.

Page 1 of 2 Version: 201501.00

TBS

TRS 116 (Special Leave Request)
undue-wad   

[1-11. l-luu'man'Resource's? Sect-ion i A   I 

 
   

If the employee is requesting extended sick leave or sick leave pool, please complete Section 111.5. Complete the rest of Section Sign and date the form and
submit it and any attachments to the executive director.
a. 

Medical El Su lemental Medical Certi?cation form All leave balances Eligible for current
received ?u e?Eponee or dependent? No ?35 have been exhausted? EYES condition? El ?0 El ?35

 

 

 

 

 

This leave quali?es for federal Family Medical Leave Act (FMLAJ coverage? No EYES I 
and Signature 
Comments:

 

 

 

Date:

5. Workplace Accommodations Coordinator:
ign
here 

c. HR'Ulrectbt Approv'at and Signatore

 

 

Leave Approval: (If modifying or denying leave request, please commot.)
Approve as Requested Deny
El Approve wiui Modi?cation

Comments:

 

HR Director:

Date:
Sign
here 

 

 

 

 

 

Please complete Section N. Sign and date HIE form and submit it and any attachments to the workplace accommodations coordinator in HR.
Leave Approval: [If modifying or denying leave request, please comment.)

Drove as Recluested Approve as Modi?ed by Other in] W: I 
Approve as Modi?ed by HR Deny

Execu lv Date:
Sign
here

 

Comments:

 

     
 

 

 

 

 

Deputy Director Review:
(Initial if revtewed by deputy director)

Page 2 of 2 Version: 2015-0100

SETTLEMENT AGREEMENT AN RELEASE

THIS AGREEMENT is made by and between the Teacher Retirement System of Texas (TRS) acting
through its undersigned designated representative and Eric Jackson for themselves and on behalf of
their respective assigns, heirs, representatives, and agents, subject to the following terms and
conditions.

In consideration of the terms and conditions and mutual agreements stated herein, the parties agree as
follows:

1.

The parties agree that, by execution of this agreement, Eric Jackson hereby tenders his
resignation from employment with TRS, such resignation to become effective as of the close
of business on September 15, 2014.

For the consideration of submitting his resignation and other valuable consideration,
including the releases contained herein, TRS hereby agrees to continue to employ Eric
Jackson under the terms and conditions set forth herein, from the date of execution of this
agreement through the effective date of resignation. TRS will make all necessary and
required deductions, including but not limited to, amounts for the TRS pension plan, federal
income tax, and social security tax from this amount in compliance with applicable laws, as
well as for any other types of deductions that were in effect with regard to Eric Jackson?s
salary from TRS for the month of April 2014.

The parties agree that Eric Jackson will remain on payroll, beginning April 14, 2014, he will
remain on leave until his vacation and state comp time leave are exhausted and then placed
on leave with pay by the Executive Director until the close of business on the effective date
of resignation. From April 14, 2014, until the effective date of resignation, Eric Jackson will
receive his current salary (less deductions in compliance with applicable laws and this
agreement) and bene?ts, unless speci?cally set out differently herein. In accordance with
state law and TRS policy, Eric Jackson will not accrue additional leave of any type after
April 14,2014.

The parties agree that beginning April 14, 2014, Eric Jackson may not retum to the TRS
premises without speci?c written authorization or conduct or attempt to conduct any TRS
business or represent TRS in any capacity. Any request for authorization to return to the TRS
premises must be made to the TRS Director of Human Resources.

The parties agree that at all times while he is employed by TRS, Eric Jackson will adhere to
all TRS employee policies and procedures.

The parties agree that Eric Jackson is entitled to seek and accept other employment, but if he
accepts employment with another public entity or state agency during the term of this
agreement, state law regarding multiple employments may prohibit payment of the
compensation described herein.

In consideration of continued employment stated in Item 2 and other good and valuable
consideration, the suf?ciency of which is hereby acknowledged, Eric Jackson hereby waives,
releases, acquits, indemni?es, holds harmless and forever discharges TRS, the trust fund, its
past, present, and future trustees, employees, representatives, and agents, in their of?cial and
individual capacities, from all obligations, demands, claims, expenses, causes of action,

Eric Jackson Settlement 1

10.

II.

13.

damages, and liability of whatever nature, whether in tort or in contract, in equity, at common
law, or by virtue of any civil rights or other federal or state constitution, law, regulation, or
rule that was raised by Mr. Jackson or could have been raised by him and arising from or
regarding his employment with TRS. Mr. Jackson expressly agrees not to sue TRS or the
fund, its past, present, and future trustees, employees, representatives, or agents in their
official or individual capacities related to his employment with TRS or to participate, unless
required by law, in any federal or state judicial or any federal or state administrative
proceeding against TRS or its trustees, employees, representatives, or agents in their official
or individual capacities related to his employment with TRS.

Eric Jackson further agrees in consideration of continued employment stated in Item 2 and
other good and valuable consideration that he will not apply for re?employment with TRS at
any time in the future.

The parties agree that this agreement does not constitute an admission of liability by either
side, all liability being expressly denied. Rather, it is entered into in order that the parties to
this agreement may ?nally resolve their differences without the burden and expense of
further administrative proceedings or litigation.

This Agreement constitutes the entire understanding and agreement between the parties with
reapect to the subject matter identi?ed in this document. There are no representations,
agreements, arrangements or understandings, oral or written, between or among the parties
relating to the subject matter of this Agreement which are not fully expressed in this
document. This Agreement may not be modi?ed or amended except by written agreement
executed by the parties hereto.

Mr. Jackson agrees to return all TRS property, including, but not limited to, documents,
computers, computer equipment, badge, and keys, in his possession and further agrees to
retrieve any TRS property that he has given to a third party and return that property to TRS.

To ensure interests are protected, it is strongly recommend that Eric Jackson have legal
counsel review this document on his behalf prior to signature.

TN WITNESS THEREOF, all of the parties hereto have executed this agreement in multiple originals

to be effective from and after 

 27/

14th day of April 2014.

Eric Jackson Da

 

 

Brian K. Guth Exe

  
 

 

 

ve Director,

Teacher Retirement System of Texas
For the Teacher Retirement System of Texas

Eric Jackson Settlement 2

 TEACHER RETIREMENT SYSTEM OF TEXAS TRSI 16
10-00 Red River Street, Austin, Texas 78701-2698 Rev. 9-97
Telephone {512) 3911-6400 or 800-223-87?8

REQUEST FOR APPROVAL OF LEAVE

(NOTE: Not for use in requesting Sick Leave Pool)

 

1. Employee Name: (Please Print} Social Security Number Department:

Eric Jackson - - lT-Network and Support

 

 

II. I request leave as speci?ed below:

DATE FROM: 0414I4  DATE T0: 091514 NO. OF HOURS 501.?5 TYPE EM
Time Time CODE

 

 

Types ofleaves and codes:

 

FORWARD TO ACCOUNTING IF FOLLOWING LEAVE REQUESTED: RETAIN IN DIVIDEPT IF
FOLLOWING LEAVE REQUESTED:
SL - Sick leave of more than 3 consecutive ML - Military leave (Attach a copy of orders; SL - Sick leave of 3 or less consecutive days
days (See #1 #2 below) 15 work days maximum per federal Y)
VC - Vacation leave
ES - Extended sick leave (See #3 below) .15 - Jury Service (Attach a copy ofsummons] CT - Compensatory time taken
EM - Emergency leave (See instructions on back) 0 - Other OT - Overtime taken (FLSA non-exempt
(See other available leave on back) employee only)

 

I. If absence was due to illness of a member of your immediate family (see de?nition on back), does heishe live in your household?_Yes El
No El. NO is checked, use of sick leave is limited to the time netessary to provide carelessistance to employee?s spouse, child other
than a minor child or parent who needs care and assistance as a direct result of a documented medical condition. Sick leave was used for
my child spouse or parent not living in my household.

2. Ifyou are absent more than three consecutive days due to illness, attach medical certi?cation include a written statement below which
is acceptable to your manager concerning your illness, and contact the FMIA Coordinator.

3. If you are requesting extended sick leave, attach medical certi?cation an_d a written justi?cation below which is acceptable to your manager
cenceroing your illness and contact the MLA Coordinator.

 

 

IV. StatemenUExplanation of circumstances (required for extended sick leave, emergency leave, or sick leave of more than 3 consecutive
days) or attach medical certi?cation.

ll" requesting extended sick leave: have you used sick leave pool for this illness? No Yes . How many hours?

 

 

 

 

 

V. I hereby certify that all information is true and correct.

 

 

Employee Signature Date

 

 

VI. Approvals

 

Team LeadcriSupervisor!

as rewsted Approved for hours DiSapproved Manager Signature: Date:
Division DirectorIChief Olaficenf

CIApproved as requested El Approved for hours Disapprovcd Executive Director Signature: Date:

 

 

VII. Approval for Extended Sick Leave and Emergency leave

EApproved as requested Dagifor hours DiSapproved 
1
Executive Director Signature: Date: 23} Ll



 

 

 

See instructions and information on back.

Release and Settlement Agreement

net-1i-

This Release and Settlement Agreement is entered into on April 2015 by Terri Krumnow
(?Krumnow?) and the Teacher Retirement System of Texas (TRS). The parties sign this Agreement in
exchange for the good and valuable consideration set forth herein, which absent this Agreement, neither
party is obligated to provide to the other and the adequacy of which is hereby acknowledged. The parties
acknowledge that the terms and conditions of this Agreement have been agreed to and that such terms are
intended to be final and binding.

1.

Terms and Conditions

By the execution of this Agreement, Krumnow hereby tenders her voluntary retirement from her
employment with TRS, such retirement to become effective as of the close of business on
October 31, 2015, referred to herein as ?date of resignation.? Until Krumnow?s date of
resignation, Krumnow will be placed on a paid leave status with TRS, where she will continue to
receive her compensation and bene?ts at her current rate but will not be required to attend work
in the of?ce. Krumnow?s last day worked in the office shall be April 30, 2015.

Krumnow agrees that after the mutual execution of this Agreement by the parties, no further
action of herself or of TRS is required to effect her resignation from all or any employment with
TRS on the date of resignation and that her resignation is hereby accepted on behalf of TRS and
is non-rescindable by her.

For the consideration of submitting her resignation and other valuable consideration, including
the releases contained herein, TRS hereby agrees to continue to employ Krumnow in a paid leave
capacity under the terms and conditions set forth herein through October 31, 2015 and to
compensate her at her current salary and pay grade through that date. Health bene?t coverage
provided to her as an employee of TRS will continue at the current level and premium rates
through October 31, 2015 for her and her Krumnow may obtain continued health
bene?t coverage after that date through COBRA at her expense. It shall be Krumnow?s
responsibility to apply for COBRA continuation coverage. This Agreement has no effect on
Krumnow?s pension benefit rights with the TRS retirement plan. Any accrued, unused leave time
that Krumnow has as of April 30, 2015 will first be deducted prior to Krumnow being placed on
administrative paid leave status. Krumnow will not accrue any leave time after April 30, 2015.
Additionally, TRS shall pay to Krumnow a one-time lump sum merit bonus of $10,000. This
bonus shall be paid with the May payroll and will be paid in accordance with applicable TRS
policies and procedures relative to withholdings on such bonus payments.

For the valuable consideration set forth herein, Krumnow fully releases and discharges the
pension trust fund; andr'or its past, present, and future trustees, employees, representatives, agents
and assigns, all both in their individual and in their official capacities, from all claims, rights and
obligations arising under common law or under federal or state constitutions or laws and relating
to, arising out of or regarding any acts or events, including but not limited to acts or events related
to her employment with TRS, occurring up to the date on which this Agreement is executed.
Krumnow further agrees to refrain from instituting, prosecuting, pressing, or in any way aiding in
the institution or prosecution of any investigation, suit, claim, action, appeal or administrative
proceeding of any kind or character whatsoever against the pension trust fund; andfor its
past, present or future trustees, employees, representatives, agents and assigns, in either their
individual or in their official capacities. In the event that on the date of the execution of this
Agreement, Krumnow has already initiated an investigation, suit, claim, action, appeal or

1

administrative proceeding of any kind or character whatsoever against the pension trust
fund; andfor its past, present or ?iture trustees, employees, representatives, agents and assigns, in
either their individual or of?cial capacities, Krumnow agrees to withdraw, dismiss, or request the
closure of the investigation, suit, claim, action, appeal or administrative proceeding. It is the
express and unequivocal intent of Krumnow to release all claims of any kind or character
whatsoever that she has or might have against the pension trust fund; andfor its employees,
agents and assigns, trustees or representatives, whether current or former, all both in their of?cial
and in their individual capacities, arising at or before the date on which this Agreement is
executed. Notwithstanding the above release, Krumnow shall be entitled to make claims and seek
any health insurance bene?ts available to her as a former employee of TRS and to apply for and
receive a refund of her TRS member account under the terms of the TRS pension plan and to
redeem her 401K and 457 retirement accounts under the terms of ti: plan and in accordance with

applicable laws. 
:1 ?it

The release and waiver by Krurnnow set out in Paragraph  above includes a waiver of her rights
under the Age Discrimination in Employment Act, the requirements for which are codi?ed in 29
U.S.C. ?626(t). This waiver of rights only applies to those rights or claims arising at or before the
date on which this Agreement is executed by Krumnow, and those rights are lmowingly waived in
exchange for the consideration which is incorporated in the settlement terms referenced in this
Agreement. Krumnow?s execution of this Agreement acknowledges that she has been
informed of her right to consult with at attorney regarding this Agreement and the rights
and claims that she is releasing and waiving. Krumnow voluntarily and knowingly manifests
her consent to this Agreement through her signature on the Agreement. Krumnow has twenty-
one (21) days within which to consider this Agreement, and seven (7) days after signing the
Agreement to revoke the Agreement. The Agreement shall be irrevocable and binding upon
Krumnow, her heirs and her assigns after the expiration of the revocation period.

In the event that Krumnow ?les any claim, lawsuit, proceeding, or in any other manner seeks to
invalidate or breach or does breach any provision of this Agreement, including but not limited to
the provisions of paragraphs 5 and 6 of this Agreement prior to her resignation date, this
Agreement will immediately become void and Krumnow?s employment will immediately
terminate. In the event that Krumnow ?les any claim, lawsuit, or proceeding, or breaches any
provision of this Agreement, including but not limited to the provisions of paragraphs 5 and 6 of
this Agreement after her resignation date, Krumnow agrees to pay TRS the sum of $25,000.
Krumnow agrees that such amount is a reasonable estimate of the damages TRS would incur as a
result of such breach. In the event that any dispute arises with respect to this Agreement, the
party who believes there may be a breach shall contact the other party in writing setting forth the
reason(s) for the belief and shall give the party ten (10) business days to remedy the matter.

Krumnow further agrees to release and hereby fully releases and discharges the pension
trust fund; andfor its past, present, and future trustees, employees, representatives, agents and
assigns, all both in their individual and in their of?cial capacities from any and all liabilities
andfor obligations under any law, rule, regulations or practice to reimburse Krumnow for
attorney?s fees and any and all costs in connection with the negotiation and execution of this
Agreement. Krumnow shall reimburse, indemnify and hold TRS harmless from any and all
claims or demands for payment of her attorney?s fees and expenses arising from, or related to her
employment, including the cessation of her employment with TRS, if any.

The parties hereto expressly acknowledge and agree that nothing in this Agreement is meant to
waive, release or extinguish any right on the part of either party to file a lawsuit to enforce this
Agreement and to seek to recover any and all damages caused by any breach of this Agreement.

2

?65'

2t.

9.

13.

However, prior to and as a condition precedent to the institution of any such legal proceeding,
the parties agree to attempt to resolve any dispute arising from or with regard to the interpretation
or performance of this Agreement through non-binding mediation presided over by a mediator
mutually acceptable to the parties. AS NOTED ABOVE, THIS AGREEMENT TO ENGAGE
IN NON-BINDING MEDIATION IS INTENDED BY THE PARTIES TO THIS
AGREEMENT TO BE AND IS IN FACT A CONDITION PRECEDENT TO THE FILING
OF ANY CLAIM OR DISPUTE INVOLVING THE INTERPRETATION OR
PERFORMANCE OF THIS AGREEMENT. Should the mediation required by this portion of
the Agreement not be successful in resolving the dispute and a lawsuit is filed seeking to enforce
this Agreement and to recover any and all damages caused by any breach of this Agreement, the
prevailing party in any such lawsuit will be entitled to recover attorney fees against the other
party to the extent authorized by law.

Krumnow warrants that this Agreement will dispose of all liability of TRS to her and to her
heirs and assigns. Krumnow further warrants that she has not assigned her rights or
claims herein released to any other individual, company or entity. Should any further claim he
made arising out of the claims and causes of action herein released for which TRS might be
liable, Krumnow will indemnify TRS, along with the pension trust fund; andr?or its past, present,
and future trustees, employees, representatives, agents and assigns from all liability for such
claims, including all costs, expenses and attorneys? fees it incurs in defending such claims.
Krumnow agrees to assume all responsibility for, and shall indemnify and hold TRS harmless
from, any and all claims, losses, damages, liability, suits, actions,judgments, costs, taxes, interest,
penalties, expenses and attorneys? fees resulting from any liability or claim of liability clue to any
federal, state or local government or agency thereof, in relation to the bene?ts provided to
Krumnow by TRS.

. Krumnow further agrees that she will not apply for reemployment with IRS at any time in the

uture.

Krumnow agrees to return all TRS property, including, but not limited to, infonnation, training
materials, documents, computers, computer equipment, badge, and keys in her possession and
further agrees to retrieve any TRS property that she has given or entrusted to a third party and
return that property to IRS at the time of her retirement.

. It is expressly understood and agreed that the terms of this Agreement are contractual and are not

merely recitals, and that the agreements contained in it and the consideration given are to resolve
all matters arising out of Krumnow?s employment with IRS. The parties deny liability, and have
not admitted and do not admit liability for any incident, events, actions, or omissions regarding or
arising out of Krumnow?s employment or separation from employment with TRS. Nothing in
this Agreement shall be construed as an admission of liability, all such liability being expressly
denied. The parties to this Agreement mutually acknowledge and represent that this is a
compromise in resolution of any disputed claims or possible claims and is made solely to avoid
the uncertainty, time, and expense of administrative proceedings, andfor litigation and to facilitate
a smooth transition for both parties in the termination of the employment relationship with
Krumnow.

Krumnow, on behalf of herself, her 552.117;552.0 and her representatives, agrees that the terms
and provisions of this Agreement, as well as its existence and any discussions or negotiations

related to this Agreement, constitute highly con?dential information and shall not be disclosed to
other persons or entities, except: as required by applicable law or if ordered by a court of
competent jurisdiction; as necessary to Krumnow?s attorney, certi?ed public accountant or tax

3





preparer for the purpose of obtaining legal advice or ?nancial planning advice, or for the ose
of preparin and ?lin tax returns or other documents required by law; Krumnow?s 552.1 or
other close  55311755302 or as necessary to any administrative agency to report wages
paid.

 

14. The provisions of this Agreement are severable and the invalidity or unenforceability of any
provision of this Agreement shall not affect the validity or enforceability of any other provision.
It is the intention of the parties that each provision of this Agreement be construed in a manner
designed to effect the purposes of the provision to the maximum extent enforceable under
applicable law.

15. This Agreement shall be binding upon and shall inure to the bene?t of the parties to this
Agreement and their respective heirs, successors, assigns, and legal representatives. This
Agreement may be executed in multiple counterparts, each of which is fully effective as an
original, but all of which together constitute one instrument.

16. This Agreement shall be construed without regard to the identity of the person or persons who
drafted the provisions contained in this document. Moreover, each and every provision of this
Agreement shall be construed as if each party to this Agreement participated equally in the
drafting of this document. As a result of the foregoing, any rule of construction that the
document is to be construed against the drafting parties shall not be applicable to this Agreement.

17. This Agreement constitutes the entire understanding and agreement between the parties with
respect to the subject matter identi?ed in this document. There are no representations,
agreements, arrangements or understandings, oral or written, between or among the parties
relating to this Agreement or the subject matter of this Agreement that are not fully expressed in
this document. This Agreement may not be modi?ed or amended except by written agreement
executed by the parties hereto.

13. This Agreement is effective immediately upon execution by the parties.

IN WITNESS WHEREOF, the parties have made and executed this Agreement on the dates
stated below.

Terri Krumnow date lam 
Sh it?
Brian Gut irie date 

Executive Director, Teacher Retirement System of Texas

 

 THE 116 (Special Leave Request)
Last Revised: 8-2015

 
 

[41. Employee Section?

 

. . .. - ..

Please ?ll out the ?elds in Secion I. Print the form double-sided [the form prints double-sided by default). Read the acknowledgement. Sign and date the form,
and submit It to your manager to complete Section 11. alter your manager returns the form to you, submit it directly to the workplace accommodations coordi-
nator, along with any required documentation as appropriate (see Section Lt). Tip: To save the form, press 

 

a. Employee Info: - - .

 

 

 

 

 

Employee Name (Last, First, Department Name: phone;
Krumnow, Terri 

.bi. LEHVB Info  . . C. REquIred.Documentatlon  I .- . .. '1i
Total Hours Requested: Leave Begin Date: Leave End Date: Date of Request:

To b: 1approved for leave Ilisted1 below, you m?st submit to the
wor ace accommo a ions war no or appropriate ocurnentatlon

952-3? 0303/15 1081316 as well as this form. Please follow the instructions below for submitting

a propriate documentation with this leave request. Important: Do not

 

 

 

 

 

 

 

 

 

 

TYPE or ?f reque?tm Emerge?? Leave other Om? P'Ease a tech the aneumentation to this form until after your manager has re-
Emergency Leave a Bereavement? Sick_l._ea_ve2ool turned the mm to 
-3, er i . Bereavement Leave
Emergency Leave Duty E'jgtm?lbl'h?l?eaje Please submit one or the following documents:
Emergency Leave - Militant Other LEBVE Obituarl? 
- Death certi?cate
0 Emergency Leave - Other a Newspaper clipping
- Funeral program
It requesting "En?lergency' Leave - Other' or ?outer Leave,? please specify. - Contact information for the funeral home
-  - Other [please include an explanation)
Specify Emergency Leave - Other: Specify Other Leave:
*Submit an explanation with the form if either of the following is true:
- You are re uesting mare than 24 hours, and the service is less than
300 miles rent your home.
- You are requesting more than 40 hours.
Juryr lilutyl Leave 
Please submit a copy of the summons.
Military Leave
When available, please submit a copy of the orders.
If uestin Bereavement Leave, lease corn late the followin Extended Sick Leave
a: 9 Please submit directly to the wort; lace accommodations coordinator in
Name of Deceased: Employeels Relationshm to Deceased: HR the Family and Medical Leave ct Certi?cation of Health Care Provider
fern-i. Forms can be obtained from the workplace accommodations coar-
dlnator.
If the funEral or other servl rn il 5 the mil a Sic? Leave Poo. 
and the location of the 6 than 300 as from Your home' please pm? 95 Please submit directly to the work lace accommodations coardinator in
HR the Family and Medical Leave ct Certi?cation of Health Care Provider
Miles from Home: Location of Service (city and slate}: form and the Supplemental Medical Certi?cation form Forms can
be obtained from the workplace accommodations coo ?lnator.
A

 
 
 

 

 

 

 

c. Employeedckn?owledgerh?nt 
I acknowledge that I have reviewed the TRS Leave policv. I understand that to be eligible for leave, I must meet the conditions de?ned In the policy.

 

 

Sign Employee Signature: Date:
here

 

 

You have certain rights under Chapters 552 and 559, Government Code. to review, uest and correct information we have on ?le about you.
For more information, oonmct the workplace acoon'lm atlons coordinator in HR.

 

 

11:. Manager and Chief/Director Section

If the employee is requesting extended sick leave or sick leave pool, please complete Section ll.a. Sign and date the form, and return it to the employee.

 

a. Abuse of te'ave and Corrective notion

 

is there documented evidence that the employee Has the employee received a second- or third-level
has abused leave within the past 12 months? NO Yes corrective action within the past 12 months? I: No Yes

 

 

Manab?r and'Chie?litirector'comments, Info, and Signatures
Comments:

 

 

Date:

Manager:
Sign
here 

Chiefl'Dlrector: Date:
Sign
here

 

 

 

 

 

The Human Resources Section and Executive Administration Section are on page 2 of this Form.

Page 1 of 2 Version: 2015-01.00

TBS TRS 116 (Special Leave Request}
Mums?. Last Revised: 8-2015

 
   

f' 111; mean Researaes?"seeias? 

If the employee is rEquesting extended sick leave or sick leave pool, please complete Section Complete the rest of Section 111. Sign and date the form and
submit it and any attachments to the executive director.

Eii?gj?ility {merit-tuba - - . -

Medical Bl. Supplemental Medical Certi?cation Form All leave balances Eligible For current
received employee or dependent? No Yes have been exhausted? No Yes condition? No YES

 

 

 

 

 

This leave quali?es for federal Famin Medical Leave Act coverage? Elves I 

-. 
Comments:

 

 

 

Workplace Accommodations Coordinator: Date:
Ign
here 

 

CL 'HR'TDir??tor approval and sesame-
Leave Approval: (If modifying 0r denying leave request, please cumment?) Comments:
Approve as Requested Deny
Approve with Modi?cation

 

 

 

HR Director: Date:
Sign
here

 

 

 

- a I

Please complete IV. Sign and date the form and submit it and al'IY attachments t0 the workplace coordinator in 

 

Loave Approval: (If modifying or denying leave request, please comment.) Comments:

mApprove as Requested BS mi Other va 

Approve as Modi?ed by HR Deny

 

 

Sign
here

Executi Diredor: Date:

 

 

   

 

Deputy Director Review:
(Initial if reviewed by deputy director}

Page 2 of 2 Version: 201501.00

SETTLEMENT AGREEMENT AND RELEASE

THIS AGREEMENT is made by and between the Teacher Retirement System of Texas (TRS) acting
through its undersigned designated representative and Christine Pack for themselves and on behalf of
their respective assigns, heirs, representatives, and agents, subject to the following terms and conditions.

In consideration of the terms and conditions and mutual agreements stated herein, the parties agree as
follows:

1.

The parties agree that, by execution of this agreement, Christine Pack hereby tenders her
resignation from employment with TRS, such resignation to become effective as of the close
of business on September 9, 2914 and that no further action is required on her part to effect
her resignation. The parties further agree that by execution of this agreement, Ms. Pack?s
resignation is accepted by TRS and that her resignation is non-rescindable by her.

For the consideration of submitting her resignation and other valuable consideration,
including the releases contained herein, TRS hereby agrees to place Ms. Pack on paid leave
at her current rate of pay through the end of the day on September 9, 2014. TRS will make
all necessary and required deductions, including but not limited to federal income tax and
social security tax from this amount in compliance with applicable laws. While on
administrative leave, Ms. Pack agrees not to conduct TRS business, to comply with
applicable policies related to her status as an employee, and not to return to the TRS premises
without the prior approval of her manager. Further, by signing this settlement agreement and
release, Ms. Pack requests that TRS stop the distribution of her salary by direct deposit and
instead send the net amount owed to her in the form of a treasury warrant made
payable to her in care of her attorney, Derek Howard, and mailed to his address of record
with TRS.

For the valuable consideration set forth herein and other good and valuable consideration, the
suf?ciency of which is hereby acknowledged, Christine Pack hereby waives, releases,
acquits, indemni?es, holds harmless and forever discharges TRS, the trust fund, its past,
present, and future trustees, employees, representatives, and agents, in their of?cial and
individual capacities, from all obligations, demands, claims, expenses, causes of action,
damages, and liability of whatever nature, whether in tort or in contract, in equity, at common
law, or by virtue of any civil rights or other federal or state constitution, law, regulation, or
rule that is raised by Ms. Pack or could be raised by her and arising from or relating to her
employment with TRS. Ms. Pack expressly agrees not to sue TRS or the fund, its past,
present, and future trustees, employees, representatives, or agents in their official or
individual capacities related to her employment with TRS or to participate, unless required by
law, in any federal or state judicial or any federal or state administrative proceeding against
TRS or its trustees, employees, representatives, or agents in their of?cial or individual
capacities related to her employment with TRS.

Christine Pack agrees that the fact of this Agreement and its terms and all disputes between

10.

ll.

12.

the parties will be kept con?dential and will not be disclosed to any third party, except as
required by law.

The parties hereto expressly acknowledge and agree that nothing in this Agreement is meant
to waive, release or extinguish any right on the part of either party hereto to ?le a lawsuit to
enforce this Agreement and to seek to recover any and all damages caused by any breach of
this Agreement. However, prior to and as a condition precedent to the institution of any
such legal proceeding, the parties hereto agree to attempt to resolve any dispute arising from
or with regard to the interpretation or performance of this Agreement through non-binding
mediation presided over by a mediator mutually acceptable to the patties. AS NOTED
ABOVE, THIS AGREEMENT TO ENGAGE IN NON-BINDING MEDIATION IS
INTENDED BY THE PARTIES TO THIS AGREEMENT TO BE AND IS IN FACT A
CONDITION PRECEDENT TO THE FILING OF ANY CLAIM OR DISPUTE
INVOLVING THE INTERPRETATION OR PERFORMANCE OF THIS
AGREEMENT.

In case any provision in this Agreement shall be invalid, illegal or unenforceable, the
validity, legality and enforceability of the remaining provisions shall not in any way be
affected or impaired thereby and such provision shall be ineffective only to the extent of such
invalidity, illegality or unenforceability. However, if inclusion of any term of this Agreement
is prohibited or voided by applicable law 0r regulation, the Agreement shall be read without
such term and shall be deemed to have been written and entered into withom such term.

Christine Pack further agrees for the consideration stated herein and other good and valuable
consideration that she will not apply for re-employment with TRS at any time in the future.

The parties agree that this agreement does not constitute an admission of liability by either
side, all liability being expressly denied. Rather, it is entered into in order that the parties to
this agreement may ?nally resolve their differences without the burden and expense of
further administrative proceedings or litigation.

This Agreement constitutes the entire understanding and agreement between the parties with
respect to the subject matter identi?ed in this document. There are no representations,
agreements, arrangements or understandings, oral or written, between or among the parties
relating to the subject matter of this Agreement which are not fully expressed in this
document. This Agreement may not be modi?ed or amended except by written agreement
executed by the parties hereto.

Ms. Pack agrees to return all TRS property, including, but not limited to, information,
training materials, documents, computers, computer equipment, badge, and keys, in her
possession and further agrees to retrieve any TRS property that she has given or entrusted to
a third party and return that property to TRS.

This Agreement is effective immediately upon execution by the parties. The parties intend
for this Agreement to be fully compliant with Texas law.

Christine Pack may have legal counsel review this document on her behalf prior to signature.

1N all of the arties hereto have executed this agreement in ml?tiple originals
to be effective from and after the '2  day of June, 2014.
'17

..I-

    

Brian K. Guthrie, Executive Director,
Teacher Retirement System of Texas
For the Teacher Retirement System of? Texas

TEACHER RETIREMENT SYSTEM OF TEXAS

1000 Red River Street, Austin, Texas 3101-2693
Telephone (512] 397-6400 or 

6
Rev. 9-9?

REQUEST FOR APPROVAL OF LEAVE

(NOTE: Not for use in nesting Sick Leave Pool}

 

1. Employee Name: (Please Print) Social Security Number

Christine Pack - -

Department:

Bene?t Counseling

 

 

ll. 1 request leave as speci?ed below:

DATE FROM: 051?08.? 4 Mil] PM
Time

DATE TO: 09109! 14

5 


Time

NO. OF HOURS TYPE EM
CODE

 

 

Types of leaves and codes:

 

FORWARD TO ACCOUNTING IF FOLLOWING LEAVE REQUESTED:

SL - Sick leave of more than 3 consecutive
days (See #1 8c #2 below)

ML Military leave (Attach a copy of orders;
l5 work days maximum per federal FY)

ES - Extended sick leave (See #3 below} JS - .lury Service (Attach a copy of summons)

0 - Other

EM - Emergency leave (See instructions on back)
[See other available leave on back)

my child spouse El, or parent not living in my household.

 

is acceptable to your manager concerning your illness, and contact the FMLA Coordinator.

concerning your illness and contact the FMLA Coordinator.

RETAIN IN IF
FOLLOWING LEAVE REQUESTED:

SL - Sick leave of 3 or less consecutive days

VC - Vacation leave
CT - Compensatory time taken

0T - Overtime taken (FLSA non-exempt
employee only)

 

1. 1t absence was due to illness of a member of your immediate family {see de?nition on back), does live in your household? Yes 
No If N0 is checked. use of sick leave is limited to the time necessary to provide eareiassistancc to employee?s spouse, child other
titan a. miner child or parent who needs care and assistance as a direct result of a documented medical condition. Sick leave was used for

2. if you are absent more than three consecutive days due to illness, attach medical certi?cation or include a written statement below which

3. if you are requesting extended sick leave, attach medical certi?cation 311d 3 written justi?cation below which is acceptable to your manager

 

 

days) or attach medical certification.

extended sick leave: have you used sick leave pool for this illness? No Yes El

W. Statementl'Explanation ofcireumstances (required for extended sick leave, emergency leave, or sick leave of more than 3 consecutive

How many hours?

 

 

 

 

 

V. I hereby certify that all information is true and correct.

 

 

Employee Signature Date

 

 

VI. Approvals

 

Team LeadertSupervisort

 

 

 

 

 

 

ClAppt-o?ved as requested El Approved for hours Uisapproved Manager Signature: Date:
Division DirectorfChief Officer!

CIApproved as requested El Approved for hours El Disapproved Executive Director Signature: Date:

VII. Approval for Extended Sick Leave and Emergency Leave

EApproved as requested Ap for hours Disapproved

Executive Director Signature:aW Date.

 

See instructions and information on back.

 

SETTLEMENT AGREEMENT AND RELEASE

THIS AGREEMENT is made by and between the Teacher Retirement System of Texas (TRS) acting
through its undersigned designated representative and Marshall Reid for themselves and on behalf of their
respective assigns, heirs, representatives, and agents, subject to the following terms and conditions.

In consideration of the terms and conditions and mutual agreements stated herein, the parties agree as
follows:

1. The parties agree that, by execution of this agreement, Marshall Reid hereby tenders his
resignation from employment with TRS, such resignation to become effective as of the close

of business on August 31, 2014.

2. For the consideration of submitting his resignation and other valuable consideration,
including the releases contained herein, TRS hereby agrees to continue to employ Marshall
Reid under the terms and conditions set forth herein, from May 14, 2014 through the
effective date of resignation. TRS will make all necessary and required deductions, including
but not limited to, amounts for the TRS pension plan, federal income tax, and social security
tax from this amount in compliance with applicable laws, as well as for any other types of
deductions that were in effect with regard to Marshall Reid?s salary from TRS for the month

of May 2014.

3. The parties agree that Marshall Reid will remain on payroll and beginning May 14 will use
all accrued, eligible leave (such as compensatory and vacation time) ?rst, and then will be
placed on leave with pay by the Executive Director until the close of business on the effective
date of resignation, with Marshall Reid receiving his current salary (less deductions in
compliance with applicable laws and this agreement) and bene?ts, unless speci?cally set out
differently herein. Marshall Reid will not accrue additional leave of any type after
May 14, 2014, consistent with applicable law and TRS policy.

4. The parties further agree that at all times Marshall Reid is entitled to seek and to accept other
employment, and that the acceptance of other employment shall not abate or cancel his right
to remain on the payroll of TRS through August 31, 2014. In the event that his employment
is with another state employer, TRS agrees to represent, when allowed and in compliance
with state law and TRS policy, that Marshall Reid?s continued TRS employment benefits
TRS and that there is no con?ict with the position he holds with TRS and to make other
reasonable effort to ensure continued payment through the date of resignation.

5. The parties agree that at all times while he is employed by TRS, Marshall Reid will adhere to
all employee policies in a manner consistent with the expectations held by TRS for

employees.

6. The parties agree that after employment with TRS ends on August _3 2014, upon request
TRS will provide a reference as outlined in the TRS reference policy. Speci?cally, unless
otherwise required by law, without written authorization from the employee, by policy TRS

10.

releases only information about a current or former employee?s employment that is subject to
disclosure under the Public Information Act.

In consideration of continued employment stated in Item 2 and other good and valuable
consideration, the suf?ciency of which is hereby acknowledged, Marshall Reid hereby
waives, releases, acquits, indemni?es, holds harmless and forever discharges TRS, the trust
fund, its past, present, and future trustees, employees, representatives, and agents, in their
of?cial and individual capacities, from all obligations, demands, claims, expenses, causes of
action, damages, and liability of whatever nature, whether known or unknown, and whether
in tort or in contract, in equity, at common law, or by virtue of any civil rights or other
federal or state constitution, law, regulation, or rule that was raised by Mr. Reid or could have
been raised by him and arising from or relating to his employment with TRS. Mr. Reid
expressly agrees not to sue TRS or the fund, its past, present, and future trustees, emplOyees,
representatives, or agents in their of?cial or individual capacities related to his employment
with TRS or to participate, unless required by law, in any federal or state judicial or any
federal or state administrative proceeding against TRS or its trustees, employees,
representatives, or agents in their official or individual capacities related to his employment
with TRS. 

The release and waiver by Marshall Reid set out in Paragraph 7 above includes a waiver of
his rights under the Age Discrimination in Employment Act, the requirements for with are
codi?ed in 29 U.S.C. Section 626(1). This waiver of rights only applies to those rights or
claims arising at or before the date on which this Agreement is executed by Mr. Reid and
those rights are knowingly waived in exchange for the consideration which is incorporated in
the settlement terms referenced in this Agreement. Marshall Reid?s execution of this
Agreement acknowledges that he has been informed of his right to consult with an attorney
regarding this Agreement and the rights and claims that he is releasing and waiving.
Marshall Reid voluntarily and knowingly manifests his consent to this Agreement through his
signature on the Agreement. Marshall Reid has twenty-one (21) days within which to
consider this Agreement and seven (7) days after signing the Agreement to revoke the
Agreement. The Agreement shall be irrevocable and binding upon Marshall Reid, his heirs
and his assigns after the expiration of the revocation period.

Marshall Reid agrees that the fact of this Agreement and its terms and all disputes between
the parties will be kept con?dential and will not be disclosed to any third party, except as
required by law.

The parties hereto expressly acknowledge and agree that nothing in this Agreement is meant
to waive, release or extinguish any right on the part of either party hereto to ?le a lawsuit to
enforce this Agreement and to seek to recover any and all damages caused by any breach of
this Agreement. However, prior to and as a condition precedent to the institution of any
such legal proceeding, the parties hereto agree to attempt to resolve any dispute arising from
or with regard to the interpretation or performance of this Agreement through non-binding
mediation presided over by a mediator mutually acceptable to the parties. AS NOTED
ABOVE, THIS AGREEMENT TO ENGAGE IN NON-BINDING MEDIATION IS
INTENDED BY THE PARTIES TO THIS AGREEMENT TO BE AND IS IN FACT A
CONDITION PRECEDENT TO THE FILING OF ANY CLAIM OR DISPUTE
INVOLVING THE INTERPRETATION OR PERFORMANCE OF THIS
AGREEMENT.

11case any provision in this Agreement shall be invalid, illegal or unenforceable, the

validity, legality and enforceability of the remaining provisions shall not in any way be
affected or impaired thereby and such provision shall be ineffective only to the extent of such
invalidity, illegality or unenforceability. However, if inclusion of any term of this Agreement
is prohibited or voided by applicable law or regulation, the Agreement shall be read without
such term and shall be deemed to have been written and entered into without such term.

Marshall Reid further agrees in consideration of continued employment stated in Item 2 and
other good and valuable consideration that he will not apply for re-employment with TRS at
any time in the future.

The parties agree that this agreement does not constitute an admission of liability by either
side, all liability being expressly denied. Rather, it is entered into in order that the parties to
this agreement may ?nally resolve their differences without the burden and expense of

further administrative proceedings or litigation.

This Agreement constitutes the entire understanding and agreement between the parties with
respect to the subject matter identi?ed in this document. There are no representations,
agreements, arrangements or understandings, oral or written, between or among the parties
relating to the subject matter of this Agreement which are not fully expressed in this
document. This Agreement may not be modi?ed or amended except by written agreement
executed by the parties hereto.

Mr. Reid agrees to return all TRS property, including, but not limited to, documents,
computers, computer equipment, badge, and keys, in his possession and further agrees to
retrieve any TRS property that he has given or entrusted to a third party and return that

property to TRS.

This Agreement is effective immediately upon execution by the parties. The parties intend
for this Agreement to be fully compliant with Texas law.

Marshall Reid may have legal ecunsel review this document on his behalf prior to signature.

IN WITNESS THEREOF, all of the parties hereto have executed this agreement in multiple originals
to be effective from and after the 14*]1 day of May 2014.

 

 1 
1
Marshall Reid Date

?gmhw

Brian K. Guthrie, Executive Director,

S?Ul?i

Teacher Retirement System of Texas
For the Teacher Retirement System of Texas

TEACHER RETIREMENT SYSTEM OF TEXAS TRSI 16
IUUO Red River Street, Austin, Texas 78701-2693 Rev. 9-9?
Telephone {512) 397-6400 or 300-223-8173 

REQUEST FOR APPROVAL OF LEAVE

(NOTE: Not for use in requesting Sick Leave Pool)

 

1. Employee Name: (Please Print) Social Security Number Department:

Marshall Reid - - 

 

 

II. I request leave as speci?ed below:

DATE FROM: 9:00 AM DATE T0: 081?29! 14 NO. OF HOURS TYPE EM
Time Time CODE

 

 

Types of leaves and codes:

 

FORWARD TO ACCOUNTING IF FOLLOWING LEAVE REQUESTED: RETAIN IN DIWDEPT IF
FOLLOWING LEAVE REQUESTED:
SL - Sick leave of more than 3 consecutive ML - Military leave (Attach a copy of orders; SL - Sick leave of 3 or less consecutive days
days (See #1 detail below) 15 work days maximum per federal 
- . - . VIC - Vacation leave
ES - Extended sick leave (See #3 below} JS - Jury Service {Attach a 0f summons) CT - Compensatory time taken
EM - Emergency leave (See instructions on back) 0 - Other 0T - Overtime taken non-exempt
- (See other available leave on back) employee only)

 

1. If absence was due to illness of a member of your immediate family (see de?nition on back), does hefshe live in your householdchecked, use of sick leave is limited to the time necessary to provide carefassistance to employee*s spouse, child other
than a minor child or parent who needs care and assistance as a direct result of a documented medical condition. Sick leave was used for
my child CI, spouse D, or_ parent El, not living in my. household.

2. If you are absent more than to roe consectitive days due to illness, attach medical certi?cation include a written statement below which
is acceptable to your manager concerning your illness, and contact the FMLA Coordinator.- 

3. If you are requesting extended sick leave, attach medical certi?cation a writtenjusti?cation below which is acceptable to your manager
concerning your illness and contact the FMLA Coordinator. .- -

 

 

IV. :StatementtEIplanation of circumstances {required for ejrte'n'ded sickleave, emergency leave, or sick leave of more than 3 consecutive
days} or attach medical certi?cation.

If requesting extended sick leave: have you used sick leave pool for this illness? No El Yes How many hours?

 

 

 

 

 

V. I hereby certify that all information is true and correct.

 

 

Employee Signature Date

 

 

VI. Approvals

 

 

Team Leaden'Supervisora?

[:IApproved as reguested El Approved for hours Disapproved Manager Signature: Date:
Division DirectorfCl-rief {Eli?ficcnIr

DApproved as requested El Approvieti for hours CIDisapproved Executive Director Signature: Date:

 

 

VII. Approval for Extended Sick Leave and Emergency Leave

EApprovedasrequested El ed for isapproved

    
 

    

Date: 23

Executive Director Signature:

 

 

 

 

See instructions and information on back.