request for military leave of absence
TRANSCRIPT
Revised 9/12/11
DOCUMENTS REQUIRED TO REQUEST A MILITARY LEAVE OF ABSENCE FOR PARTICIPATION IN THE EMBP-DP
1. The following documents are attached for your review and guidance:
Item 1: Commissioner Hirst’s Memorandum to Members of the National Guard and Reservists dated July 15, 2010 Item 2: Terms of the EMBP – DP (Revised 6/2011) Item 3: USERRA Flyer
2. Submit the following forms to the Military and Extended Leave Desk prior to your deployment:
***ORIGINAL DOCUMENTS ARE REQUIRED***
Item 4: Request for Military Leave of Absence (Fill out online and print) Item 5: Commanding Officer’s Endorsement (Fill out online and print) Item 6: DP-2520 (r 6/11): Enrollment in the Extended Military Benefits Program Differential Pay
(EMBP-DP) (Print, fill out and notarize) OR Item 7: DP-2531: Declination of Extended Military Benefits Program (if you elect not to participate in the EMBP- DP) (Print, fill out and notarize)
Item 8: DP-2532: Time Balance Usage Form (prepared by timekeeper and member) Recent Leave and Earnings Statements (“LES”) within ninety (90) days of the execution date on
Enrollment agreement Item 9: Reemployment Rights (Print and sign) Copy of official military orders Item 10: Property Receipt – Discontinuance of Service (Form PD520-013)
3. Uniformed members who are requesting to be assigned to M.E.L.D. for a Military Leave of Absence must surrender the following Department property:
Property Clerk’s Voucher for ALL weapons Receipt for member’s shield from Shield Unit, located at 1 Police Plaza, Rm. 502 Receipt for member’s Metro Card, LIRR/Metro North Card from Employee Management
Division, located at 1 Police Plaza, Rm. 1014A Receipt or notate on Property Receipt – Discontinuance of Service (Form PD520-013) (Item 10)
for member’s Restricted/ HQ Annex Parking Permit Safeguard and notate on Property Receipt – Discontinuance of Service (Form PD520-013) (Item
10) for member’s helmet, mace and summonses If applicable, receipt for member’s personal portable radio and all accessories from
Communications Division, Electronics Section located at 50-16 59th Place, Woodside, NY If applicable, receipt for member’s personally assigned cellular telephone and all accessories from
Communications Division, Telecommunications Unit, located at 1 Police Plaza, Rm. 910B
*** Necessary receipts/vouchers must be forwarded to the Military and Extended Leave Desk*** You may, at your option, retain your ID card, Patrol Guide, vest, and name plate
4. For further questions, contact the Military and Extended Leave Desk located at One Police Plaza, Rm. 1008, New York, NY 10038 at (646) 610 – 5513 or via the MELD website at [email protected]. Rebecca Mayo Sergeant C.O., Military and Extended Leave Desk
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DEPARTMENT OF CITYWIDE ADMINISTRATIVE SERVICES
EDNA WELLS HANDY, COMMISSIONER
TERMS OF THE EXTENDED MILITARY BENEFITS PROGRAM
These terms shall govern the Extended Military Benefits Program (“EMBP”).
1.0 DEFINITIONS
1.1 “Employee” shall mean any individual employed by the City of New York. It shall
include any individual appointed to a classified or unclassified position, and, in addition
to employees permanently appointed to positions, includes employees serving by
provisional and temporary appointments.
1.2 “Agency” shall mean the agency to which an employee is appointed.
1.3 “Covered Operation” shall mean Operation Enduring Freedom, Operation Iraqi Freedom,
Operation Noble Eagle or operations specifically connected with Homeland Security.
1.4 “Ordered Military Duty” shall mean military duty performed as a member of the
organized militia or reserve forces or reserve components of the armed forces of the
United States with or without consent of that member.
Enlisted military personnel and/or members on voluntary military duty are not eligible for
participation in the Extended Military Benefits Program.
1.5 “Period of Coverage” shall mean the period during which an employee who is called up
for Ordered Military Duty for a Covered Operation receives his or her differential pay
under the Terms of the EMBP – Differential Pay Program (“EMBP – DP”). (See Sections
4.1 and 4.2 of these Terms.) It shall commence upon the expiration of the employee’s
Statutory Entitlement (if the employee is entitled to one) as that term is defined in Section
1.8 of these Terms; or, if the employee so chooses, the use of any available Leave
Balances, whichever is later. For a definition of Leave Balances, see Section 1.9 of these
Terms. The Period of Coverage shall expire at the end of the next calendar day after
Ordered Military Duty ceases.
1.6 “City Salary” shall mean gross City salary before taxes and other deductions are
deducted.
1.7 “Military Pay” shall mean gross “base pay.”
Note: The City had earlier included allowances for food and housing in the definition of
“Military Pay.” This is no longer the case.
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1.8 “Statutory Entitlement” shall mean the City salary received by an employee called up for
Ordered Military Duty for the first 30 regularly scheduled work days, as provided by
New York State Military Law Section 242(5-a). Employees can use no more than 30
regularly scheduled work days in any single continuous period of Ordered Military Duty
(even if the Ordered Military Duty extends to more than one year).
1.9 “Leave Balances” shall mean annual leave (including equivalent terms for annual leave
as used by the uniformed agencies), compensatory time, vested annual leave or
compensatory time balances. Vested balances may only be used after all other balances
are exhausted. Leave Balances do not include sick leave balances, where sick leave is
provided in leave regulations or pursuant to collective bargaining agreements.
2.0 ELIGIBILITY
2.1 Except as provided by Sections 2.2 of the Terms, an employee is eligible for the EMBP -
DP if he or she has been called up for Ordered Military Duty in connection with a
Covered Operation.
2.2 In order for an agency to evaluate whether the Ordered Military Duty is in connection
with a Covered Operation, an employee must submit his or her military orders. Failure to
provide military orders renders an employee ineligible to participate in the EMBP - DP.
Note: Although Section 4312(a)(1) of the Uniformed Services Employment and
Reemployment Rights Act (“USERRA”) requires, in almost all cases, an employee to
provide his or her employer with advance notice of military service, USERRA does not
require that the notice be in writing. USERRA permits oral notice. However,
notwithstanding this provision of USERRA, in order to participate in the EMBP - DP, an
employee must submit his or her military orders.
3.0 DECLINATION TO PARTICIPATE IN THE EMBP - DP
3.1 An employee who is otherwise eligible to participate in the EMBP – DP may decline to
participate.
3.2 An employee who wishes to decline participation in the EMBP - DP shall be asked to
sign and have notarized form DP-2531: Declination of the Extended Military Benefits
Package (“Declination”), and should return such form to his or her agency representative
authorized to accept such form.
3.3 In the event an employee does not submit a DP-2531, but has taken an action which is
deemed a declination, or has failed to submit required documentation as listed in Section
4.0, an agency representative must note and retain in the records the basis for the
agency’s determination that the employee declined to participate in the EMBP - DP.
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3.4 In the event that an employee otherwise eligible to participate in the EMBP - DP declines
to participate, he or she is entitled but not required to use all or any portion of available
Leave Balances upon the exhaustion of the Statutory Entitlement.
3.5 Upon the exhaustion of any Statutory Entitlement (and if requested, after using all or any
portion of accumulated Leave Balances), an employee who declines to participate in the
EMBP - DP shall be placed on “Military Leave Without Pay” status.
3.6 Placement on “Military Leave Without Pay” stops the generation of paychecks. All
employee and employer contributions, including all voluntary contributions deducted
from paychecks cease, such as contributions to the Deferred Compensation Plan and the
Combined Municipal Campaign.
Note: In general, federal and State law provisions may permit an employee who was on
Ordered Military Duty without pay to obtain pension credit and maintain pension rights
for the period of military leave. An employee returning from Ordered Military Duty
should contact his or her retirement system or pension fund for a complete explanation of
available pension rights.
3.7 An employee who declines to participate in the EMBP - DP will not, after the exhaustion
of any Statutory Entitlement, accumulate any Leave Balances, including leave types not
included in the definition of Leave Balances in Section 1.9 of these Terms, such as sick
leave.
3.8 Notwithstanding an employee’s placement on “Military Leave Without Pay,” an
employee who declines to participate in the EMBP - DP will be granted Special Leave of
Absence Coverage (“SLOAC”), which provides continuation of health plan coverage for
up to four months for those on leave without pay.
3.9 Upon the conclusion of SLOAC, an employee who declines to participate in the EMBP -
DP will be eligible for continuation of health insurance benefits for a period of time as
provided by USERRA.
4.0 PARTICIPATION IN THE EMBP - DP
4.1 An employee who participates in the EMBP - DP shall continue to receive the difference
between his or her City salary and military pay, where the military pay is less than the
City salary, during the Period of Coverage. An employee whose military pay is greater
than his or her City salary will not receive any differential pay, but, if such employee is
serving in a Covered Operation, will continue to accrue leave balances and continue his
or her preexisting healthcare benefits.
4.2 Notwithstanding Section 4.1, all deductions for federal, state and City taxes, FICA, and
all other amounts which, by law and/or contract, are required to be deducted shall
continue to be deducted from the City salary during the Period of Coverage. The
employee is responsible for cancelling, if so desired, any voluntary deductions prior to
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being deployed as they will not automatically cease and will be deducted from the
differential pay.
4.3 An employee who participates in the EMBP - DP shall continue to accrue annual leave
(including equivalent terms for annual leave as used by the uniformed agencies) and,
where applicable, sick leave during the Period of Coverage, as provided in the applicable
time and leave regulations or applicable collective bargaining agreements.
4.4 An employee who participates in the EMBP - DP shall continue to receive the health
insurance benefits he or she had been enrolled in prior to the Period of Coverage.
Deductions from the employee for any premiums or optional health insurance coverage
will continue to be made during the Period of Coverage. If the employee is enrolled in
health insurance that requires the employee to pay a contribution out of his/her paycheck
and the employee’s differential pay does not fully cover this contribution, will be billed
for the outstanding balance.
4.5 In order to participate in the EMBP - DP, an employee must sign and have notarized form
DP-2520: Enrollment In the Extended Military Benefits Package (“Enrollment”) and
must return such form along with a recent Leave and Earnings Statement (“LES”) to his
or her agency representative authorized to accept such form. Only LESs for pay periods
within 90 days of the execution date on the employee’s Enrollment agreement will be
accepted as proof of current military pay and used to calculate the employee’s differential
pay under the EMBP - DP.
An employee who fails to submit his or her military orders or fails to submit an LES with
the Enrollment (and, therefore, does not allow the agency to determine whether the
employee is serving in a Covered Operation or whether the employee is to receive any
differential pay) shall be deemed to have declined participation in the EMBP – DP;
therefore, he or she will not receive any differential pay or any additional benefits of the
EMBP-DP.
4.6 In order to participate in the EMBP- DP, you must submit all of the following forms to
the agency representative authorized to accept such forms:
Military Orders for a covered operation
DP-2520: Enrollment In the Extended Military Benefits Package
Recent LES
Your contact information while deployed (Page 3 of DP-2520)
Failure to submit any of the above will be deemed a declination to participate in the
EMBP-DP.
4.7 A copy of these Terms must be attached to an Enrollment when distributed to the
employee.
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4.8 Except as specified in Section 7 of these Terms, participation in the EMBP - DP expires
at the conclusion of the Period of Coverage.
4.9 Any monies received after the conclusion of the Period of Coverage must be repaid in
full according to the Terms of the EMBP – Full Pay/Repayment Plan1 (“EMBP –
FP/RP”), as specified in Section 6, below. Overpayments received under the EMBP – DP
do not qualify for an administrative adjustment or early repayment incentive.
5.0 USE OF LEAVE BALANCES
5.1 Upon the exhaustion of any available Statutory Entitlement, an employee is entitled, but
is not required, to use all or any portion of his or her Leave Balances in order to continue
to receive his or her City salary. In addition to the Leave Balances as described in Section
1.9 of these Terms, an employee may also use, if he or she is entitled to it, a floating
holiday.
5.2 The employee will receive his or her full City salary while using Leave Balance. There is
no obligation to repay any salary received while using Leave Balances.
5.3 An employee is entitled to use all or any portion of his or her Leave Balances whether or
not the employee participates in the EMBP - DP.
5.4 Where an employee elects to participate in the EMBP - DP, the employee’s Period of
Coverage under the EMBP - DP will not commence until he or she has used the Leave
Balances he or she has chosen to use.
Note: Because an employee will receive the difference between his or her City salary and
Military Pay during the Period of Coverage, using Leave Balances will delay the
commencement of the Period of Coverage.
6.0 REPAYMENT
6.1 An employee who was previously enrolled in the EMBP – FP/RP, or who received pay
under the EMBP – DP to which he/she was not entitled, will be subject to repayment
conditions under these Terms; repayment cannot be made in any other manner unless
specifically authorized by the Commissioner of the Department of Citywide
Administrative Services (“DCAS”).
6.2 The amount to be reimbursed to the City by an employee must be determined by using
the formula approved by DCAS. No agency is authorized to use a different formula for
determining the amount to be reimbursed unless specifically authorized by the
Commissioner of DCAS.
1 The Extended Military Benefits Program promulgated by the City from October 2001 until November 4, 2008, was
a “full pay/repayment plan” program. That program is no longer being offered for new periods of military service.
However, except as otherwise noted in these terms, the repayment terms governing repayments under the EMBP –
FP/RP will govern repayments required under the EMBP – DP.
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A 7.65% adjustment for Social Security and Medicare and a 15% administrative
adjustment will be deducted from the repayment obligation of all enrollees on the EMBP
– FP/RP. No adjustments will be applied towards those making repayment for
overpayments made under the EMBP – DP plan.
Any EMBP-FP/RP participant who repays his or her debt amount before his or her last
scheduled payment will receive a 5% discount off the remaining amount owed at the time
of full repayment. This early repayment incentive does not apply to repayment made for
overpayments on the EMBP - DP.
6.3 Except where an employee is called up for subsequent Ordered Military Duty, if the
employee elected to participate in the EMBP – FP/RP and, in having done so, incurred a
repayment obligation, the reimbursement must be fully effectuated within ten years of the
date of return from ordered military duty according to the terms and conditions as
specified in New York State Military Law Section 242(5-a).
6.4 An employee to whom this Section 6.0 applies must be provided with form DP-2541:
Employee Repayment Plan Selection and Agreement for EMBP Enrollees. Upon
receiving the form, the employee will have fourteen (14) calendar days in which to select
a repayment method.
6.4(a) If the employee chooses to reimburse the full amount within thirty (30) days of
completing and returning to the agency the DP-2541, the employee may pay by
certified check, money order or credit card; or by applying any Leave Balances to
the remaining amount; or by a combination of these methods.
6.4(b) If an employee opts to not pay the entire amount within thirty (30) calendar days
of completing and returning to the agency the DP-2541, the employee may elect to
reduce the total amount owed by certified check, money order or credit card; or by
applying any Leave Balances to the remaining amount; or by a combination of
these methods. After these adjustments are made, the employee will be entered into
a repayment plan for payroll deductions in the amount of 7.5% of his or her base
pay of City salary on the effective date of New York State Military Law Section
242(5a) or on the date of return to City service, whichever is later. Deductions will
be taken out of the employee’s weekly or bi-weekly paycheck.
6.5 Any amount owed at the conclusion of the ten years will be payable in one lump sum,
either by certified check, money order or credit card, and/or by applying any Leave
Balances.
6.6 Where an employee does not cooperate in good faith to reach a repayment plan or refuses
to sign a form DP-2541: Employee Repayment Plan Selection and Agreement for EMBP
Enrollees, the agency shall start payroll deductions in the amount of 7.5% of the
employee’s base pay of City salary on the effective date of New York State Military Law
Section 242(5-a) or on the date of return to City service.
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6.7 Reimbursements shall cease, and an agreed-upon repayment plan deadline shall no longer
be effective, in the event that an employee is called-up for a subsequent period of
Ordered Military Duty (whether or not in connection with a Covered Operation), unless
the employee specifically requests otherwise. A new repayment plan deadline must be
devised upon the employee’s return from the subsequent period of Ordered Military
Duty. The employee will be allotted the balance of the ten years remaining for repayment
upon return from his or her subsequent period of Ordered Military Duty.
6.8 When an employee separates from City service, the employee will be entered into a
repayment plan for monthly payments in the amount of 7.5% of his or her gross monthly
base pay of City salary on the effective date of New York State Military Law Section
242(5-a) or on the date of separation from City service, whichever is later; or for a retired
City employee, an amount equal to 7.5% of the employee’s gross monthly pension check.
6.9 The full remaining balance owed must be repaid within the same amount of time that
he/she would have had, had he/she not separated from City service. Any amount owed at
the conclusion of the repayment period will be payable in one lump sum, either by
certified check, money order or credit card. Monthly payments may be made by certified
check, money order or credit card; or by applying any Leave Balances to the remaining
amount; or by a combination of these methods. In addition, eligible employees may also
use managerial lump sum or separation leave for this purpose (as appropriate).
7.0 SUBSEQUENT CALL-UPS FOR ORDERED MILITARY DUTY
7.1 Participation in the EMBP - DP will be deemed to have expired at the conclusion of a
Period of Coverage. If the employee is to begin a subsequent period of Ordered Military
Duty in connection with a Covered Operation a new Enrollment must be executed by the
employee along with all forms referenced to in Section 4.6 above. An employee should
contact his or her military liaison officer and submit the new military orders and
paperwork as soon as reasonably possible after his or her receipt of such orders.
7.2 In the event that an employee is to begin a subsequent period of Ordered Military Duty in
connection with a Covered Operation and the employee elects not to participate in the
EMBP - DP in connection with this subsequent call-up, it is the responsibility of the
employee to provide his or her agency with form DP-2531: Declination of the EMBP -
DP prior to the commencement of the subsequent period of ordered military duty.
8.0 WITHDRAWAL FROM THE EMBP - DP
8.1 An employee who has enrolled in the EMBP - DP may withdraw his or her enrollment in
the EMBP - DP at any time by submitting a notarized statement to that effect to his or her
agency. The Period of Coverage shall be deemed to end upon receipt of such notarized
statement by the agency.
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9.0 REELECTION TO ACCEPT THE EMBP - DP
9.1 An employee who has withdrawn from the EMBP - DP and who otherwise meets the
eligibility requirements, as specified in Section 2.1 of these Terms, may re-elect to accept
the EMBP - DP at any time by executing a new Enrollment in the Extended Military
Benefits Package, and by otherwise complying with these Terms.
U.S. Department of Labor1-866-487-2365
U.S. Department of Justice
YOUR RIGHTS UNDER USERRA THE UNIFORMED SERVICES EMPLOYMENT
AND REEMPLOYMENT RIGHTS ACT
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Publication Date—July 2008
REEMPLOYMENT RIGHTS
You have the right to be reemployed in your civilian job if you leave thatjob to perform service in the uniformed service and:
� you ensure that your employer receives advance written or verbalnotice of your service;
� you have five years or less of cumulative service in the uniformedservices while with that particular employer;
� you return to work or apply for reemployment in a timely mannerafter conclusion of service; and
� you have not been separated from service with a disqualifyingdischarge or under other than honorable conditions.
If you are eligible to be reemployed, you must be restored to the job andbenefits you would have attained if you had not been absent due tomilitary service or, in some cases, a comparable job.
RIGHT TO BE FREE FROM DISCRIMINATION AND RETALIATION
If you:
� are a past or present member of the uniformed service; � have applied for membership in the uniformed service; or� are obligated to serve in the uniformed service;
then an employer may not deny you:
� initial employment;� reemployment;� retention in employment; � promotion; or � any benefit of employment
because of this status.
In addition, an employer may not retaliate against anyone assisting inthe enforcement of USERRA rights, including testifying or making astatement in connection with a proceeding under USERRA, even if thatperson has no service connection.
HEALTH INSURANCE PROTECTION
� If you leave your job to perform military service, you have the rightto elect to continue your existing employer-based health plancoverage for you and your dependents for up to 24 months while inthe military.
� Even if you don't elect to continue coverage during your militaryservice, you have the right to be reinstated in your employer'shealth plan when you are reemployed, generally without any waitingperiods or exclusions (e.g., pre-existing condition exclusions) exceptfor service-connected illnesses or injuries.
ENFORCEMENT
� The U.S. Department of Labor, Veterans Employment and TrainingService (VETS) is authorized to investigate and resolve complaintsof USERRA violations.
� For assistance in filing a complaint, or for any other information onUSERRA, contact VETS at 1-866-4-USA-DOL or visit its website athttp://www.dol.gov/vets. An interactive online USERRA Advisor canbe viewed at http://www.dol.gov/elaws/userra.htm.
� If you file a complaint with VETS and VETS is unable to resolve it,you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, forrepresentation.
� You may also bypass the VETS process and bring a civil actionagainst an employer for violations of USERRA.
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1-800-336-4590
The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA,and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees.
Office of Special Counsel
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers
from discriminating against past and present members of the uniformed services, and applicants to the uniformed services.
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REQQUEST FOR MILITARY LEAVEE OF ABSEENCE AND (ACCEPT//DECLINE)) THHE EXTENNDED MILTTARY BENEFITS PROOGRAM-DIIFFERENTTIAL PAY
(EMBP-DP) FOR ORRDERED MMILITARY DUTY
DDATE (mm//dd/yyyy)
RRANK/TITLLE LAAST NAMEE FIRST NAME MI MTAX #
CCOMMANDD APPPT DATE LASST 4 DIGITTS OF SOCIIAL SECURRITY #
IIt is requesteed that I be ggranted a Millitary Leave of Absence starting 00001 hours, ____________________.
TThe followinng original fforms are attached:
Notarizzed Form DPP-2520: Enrrollment in Differeential Pay Prrogram (EMBBP-DP)
OR
Notarizzed Form DPP-2531: Decclination of
II will have utilized my 30 work dayss under the sttatutory ent 00001 hours, _ ________.
DATE (mm//dd/yyyy)
II will be assiigned to the MMilitary andd Extended LLeave Desk
DAATE (mm/ddd/yyyy)
tthe Extendedd Military Benefits Proggram-
EMBP-DP
iitlement as oof:
eeffective: __________ ___________ ______.00001 hours, _ ________, ass per ______ ________________ Phonee # ________ DDATE (mm/ddd/yyyy) TIME KEEPER’S
TThe followinng original fforms are attached: Form DDP- 2532: Time Balancee Usage Militarry Orders Recentt Leave and EEarnings Staatement (“L Signedd Reemploymment Rights
RANK, NAMME AND PPHONE NUMMBER
EES”)
______________
______________
______________ ______________
Choose One Option:
I request to be paid for _____ vacation days/annual leave hours, _____ chart days,
_____ hours accrued time.
NUMBER
NUMBER NUMBER
OR
I request not to be paid for vacation, chart or accrued time; I have exhausted my 30 work days.
SELECT ONE OPTION BELOW IF ACCEPTING OR DECLINING EMBP-DP
I have reviewed and understand the terms of the EMBP – Differential Pay Program (“EMBP – DP”), Form DP-2520, which entitles me to receive the difference between my City salary and military pay, where the military pay is less than the City salary during my Period of Coverage. I also understand that if my military pay is greater than my City salary, I will not receive any differential pay, however, under a Covered Operation, I will continue to accrue leave balances and continue my preexisting healthcare benefits. I have attached Form DP-2520: Enrollment in EMBP-DP.
OR
I understand that I will be placed on Military Leave Without Pay upon declining the EMBP-DP. Form DP-2531: Declination of EMBP-DP is attached. I am aware that while on a military leave of absence without pay, I am entitled to 18 weeks of health insurance under the Military Special Leave of Absence Coverage (Military SLOAC).
I have surrendered the following Department property as required and have notated it on the Property Receipt - Discontinuance of Service Form: Form PD 520-013:
All of my weapons have been vouchered at __________________________. Command/Location Vouchered
The voucher number(s) are as follows:
VOUCHER # VOUCHER # VOUCHER # VOUCHER #
Shield (forwarded to the Shield and ID Desk at 1 Police Plaza, Rm. 502)
Metro Card (forwarded to Employee Management Division at 1 Police Plaza, Rm. 1014A)
LIRR/Metro North Card (forwarded to Employee Management Division at
1 Police Plaza, Rm. 1014A)
Restricted/HQ Annex Parking Permit
Helmet, Mace, and Summonses
Portable Radio & Accessories, if applicable
Personally Assigned Cellular Phone (Forward to Communications Division, Telecommunications Unit at 1 Police Plaza, Rm. 910B), if applicable
_________________________________
_________________________________
_________________________________
_______________
______________________ _______ __________
______________________ ______________________
_________________________________________
__________________________________
__________________________________
_________________________________
_______________
______________________ _______ _________
______________________ ______________________
_________________________________________
While on leave, I request that my paychecks/direct deposit slips and other correspondence be mailed to:
NAME
RELATIONSHIP TO MEMBER
ADDRESS
APARTMENT #
CITY STATE STATE ZIP CODE
TELEPHONE NUMBER CELL PHONE NUMBER
EMAIL ADDRESS
My emergency contact information is as follows:
NAME
RELATIONSHIP TO MEMBER
ADDRESS
APARTMENT #
CITY STATE ZIP CODE
TELEPHONE NUMBER CELL PHONE NUMBER
EMAIL ADDRESS
STATE
_________________________________
_______________________________________________
_________________________________
______________________ _______ __________
______________________ ______________________
_________________________________________
_________________________________________
_________________________________________
_________________________________
__________________________________
__________________________________
While on leave, my Military Unit administrative contact information is as follows:
UNIT NAME
RANK/NAME OF MILITARY CONTACT PERSON
ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER CELL PHONE NUMBER
UNIT EMAIL ADDRESS
While on military leave my personal contact information is as follows:
PERSONAL EMAIL ADDRESS
MILITARY EMAIL ADDRESS
PERSONAL CELL PHONE
I agree to notify the Commanding Officer, Military and Extended Leave Desk in writing of any change to my permanent resident address or telephone number while on leave.
I, _______________________________________ also understand that I will report all Police Rank and Full Name of MOS
Incidents/Off-Duty Incidents, Family Offenses, and Domestic Violence Incidents, as per Patrol Guide
Procedures 212-32 and 208-37.
SIGNATURE OF MEMBER
RANK/TITLE/ NAME PRINTED
FIRST ENDORSEMENT Commanding Officer, _________________________________, to Commanding Officer, Military and COMMAND
Extended Leave Desk, ________________. Contents noted. Military Orders and/or ordered military DATE (MM/DD/YYYY)
duty have been verified. The member has surrendered all Department property as listed on the attached
Property Receipt-Discontinuance of Service Form. Member’s shield and Metro Card have been turned
into the Employee Management Division. All firearms have been vouchered and noted on the attached
Property Clerk Invoice. ______________________________, Tax #_________ will be assigned to the RANK/ NAME OF MOS
Military And Extended Leave Desk effective 0001 hours, ______________ as per DATE (MM/DD/YYYY)
________________________________. Recommend APPROVAL. RANK/NAME COMMAND TIMEKEEPER ______________________________ Commanding Officer Signature
______________________________ Commanding Officer Name Printed
______________________________ Rank/Title
DP-2520 r12/2010 Page 1 of 3
DEPARTMENT OF CITYWIDE ADMINISTRATIVE SERVICES
EDNA WELLS HANDY, COMMISSIONER
ENROLLMENT IN THE EXTENDED MILITARY BENEFITS PROGRAM
1. I have been provided information regarding the New Extended Military Benefits Program (“EMBP”), and the Memorandum from Martha K. Hirst to Members of the National Guard and Reserves dated July 24, 2008. 2. I have read the attached “Terms of the Extended Military Benefits Program” (“Terms of the EMBP”) which explains the benefits and consequences of participating in the EMBP and the consequences of declining to participate. 3. I have been advised that there may be financial and/or tax consequences for me and/or my family if I participate in the EMBP both while I am serving on Ordered Military Duty and upon my return from such duty, and I have been advised to consult with tax, financial and/or legal advisors when considering whether to participate in this program. 4. I understand that, in participating in the EMBP, I will, during my Period of Coverage (as that term is defined in the Terms of the EMBP), continue to receive the difference between my City salary and my military pay, if my military pay is less than my City salary. 5. I understand that my eligibility to participate in the EMBP ceases upon the expiration of my Period of Coverage, and therefore, I am not entitled to receive any of my City salary after my Period of Coverage has expired and before I return to work. (See Paragraph (10).) I agree to notify the appropriate agency representative (as identified by my agency) no later than the expiration of my Period of Coverage that such Period has expired. I will advise the agency representative how any continued absence (until my return to work) should be characterized by the agency; for example, using Leave Balances or placing me on leave without pay. I agree to reimburse, in full, any City salary I may receive after the expiration of my Period of Coverage, but before I return to work or any overpayments made in error. Paragraphs (6) through (9): Repayment in the event of overpayment made in error and/or continuation in EMBP-DP beyond the Period of Coverage 6. I agree that upon my return to work after my Ordered Military Duty has ceased, I will cooperate with personnel in my agency with respect to entering a repayment plan for any City salary paid in error (and executing a form DP-2541: Employee Repayment Plan Selection and Agreement for EMBP Enrollees), if applicable, as specified in the Terms of the EMBP. 7. I understand and agree that in the event that I fail to cooperate with my agency’s efforts with respect to entering a repayment plan and/or executing a form DP-2541: Employee Repayment Plan Selection and Agreement for EMBP Enrollees, if applicable, my agency is authorized to commence payroll deductions of 7.5% of my base pay of City salary on the date of return to City service, whichever is later for the amount of my overpayment. 8. I agree that, except in the event that I am called to serve a subsequent term of Ordered Military Duty, I shall fully reimburse any overpayments received as per the Terms of the EMBP. 9. I agree that this obligation to make full reimbursement to the City pursuant to this agreement continues even in the event that I transfer to another City agency or in the event I resign, retire or am otherwise separated from City service. Further, I agree that upon separation from City service, I will repay any remaining balance of any amount owed pursuant to the Terms of the EMBP.
DP-2520 r12/2010 Page 2 of 3
10. I have been advised that although I am required to contact my agency for the purposes of the EMBP in the manner specified in Paragraph (5) above, the federal Uniformed Services Employment and Reemployment Rights Act (“USERRA”) may provide me with a longer period of time after my Ordered Military Duty ends before I am required to actually report back to work. 11. I will provide my military liaison officer with the information of my Contact Person in the USA. In the event that I am not reachable while I am serving overseas, my military liaison officer can contact my Contact Person. This person may be responsible for turning in my LESs and any other necessary documents or payments when I am unable to do so in order to ensure that my case will be handled in a timely and proper manner. 12. I agree that this agreement shall in no way limit the right of the City to exercise any other lawful remedy available to it to recover any amount not repaid by me in accordance with the repayment plan into which I enter with my agency. 13. I have read and considered the above-mentioned documents and factors, and do hereby agree to the Terms of the EMBP-DP.
_____________________________________
Print Name _____________________________________
Signature ____________________________________ Date _________________________________ Notary
DP-2520 r12/2010 Page 3 of 3
DEPARTMENT OF CITYWIDE ADMINISTRATIVE SERVICES
EDNA WELLS HANDY, COMMISSIONER
CONTACT INFORMATION FOR EMPLOYEES ON
THE EXTENDED MILITARY BENEFITS PROGRAM (EMBP) Employee Name: _________________________________________________________________________ Employee Identification/Reference Number: ___________________________________________________ Contact information while on EMBP (email address and phone number if available): ___________________ _______________________________________________________________________________________ Contact Person (must be in the USA): Name: ___________________________________________________________________________ Address: _________________________________________________________________________ _________________________________________________________________________________ Phone: ___________________________________________________________________________ Email: ___________________________________________________________________________ I authorize my Contact Person to answer any/all question while I am on the EMBP program. This individual will have access to my military pay information while I am deployed and will be able to provide The City of New York with any required documentation or payments (i.e. health insurance premiums, Union dues, etc) on my behalf.
_____________________________________
Signature ____________________________________ Date _________________________________ Notary
DEPARTMENT OF CITYWIDE ADMINISTRATIVE SERVICES
EDNA WELLS HANDY, COMMISSIONER
DECLINATION OF THE EXTENDED MILITARY BENEFITS PROGRAM
1. I have been provided information regarding the New Extended Military Benefits Program (“EMBP”), including the Terms of the Extended Military Benefits Program and the Memorandum from Martha K. Hirst to Members of the National Guard and Reserves dated July 24, 2008. 2. I have read all the information provided to me and I hereby decline the Extended Military Benefits Program. 3. I have been advised that I may, if eligible, elect to accept the package at a later time by complying with the Terms of Extended Military Benefits Program. _____________________________________ Print Name _____________________________________ Signature ____________________________________ Date _________________________________ Notary
DP-2531 r 12/2010
DEPARTMENT OF CITYWIDE ADMINISTRATIVE SERVICES EDNA WELLS HANDY, COMMISSIONER
TIME BALANCE USAGE FORM This “Time Balance Usage Form” is intended to provide you with an opportunity to elect to use all or a portion of your Leave Balances after you exhaust your Statutory Entitlement in order to continue to receive your City Salary while on Ordered Military Duty. If you have enrolled in the Extended Military Benefits Package (“EMBP”): Please refer to the Terms of the EMBP with respect to how use of Leave Balances will affect when your Period of Coverage commences. INSTRUCTIONS: You must mark one box in either Part 1 or Part 2 of this form with an “X.” You must also enter your personal data and signature at the bottom of this form. PART 1: For employees who enroll in the EMBP.
Upon the exhaustion of any available Statutory Entitlement, I elect to use my Leave Balances before my Period of Coverage commences under the EMBP.
Agency Completes: Employee Completes: Number of annual leave days available: Number of annual leave days I wish to use before my
Period of Coverage commences: Amount of compensatory time in days available: Amount of compensatory time in days I wish to use
before my Period of Coverage commences: Number of other leave days available (specify): Number of other leave days I wish to use before my
Period of Coverage commences:
Upon the exhaustion of any available Statutory Entitlement, I elect to immediately commence my Period of Coverage under the EMBP; I elect not to use any Leave Balances.
PART 2: For employees who do not enroll in the EMBP.
Upon the exhaustion of any available Statutory Entitlement, I elect to use my Leave Balances. I understand that when I cease using Leave Balances, my approved leave of absence will continue, but that I shall be placed on Military Leave Without Pay.
Agency Completes: Employee Completes: Number of annual leave days available: Number of annual leave days I wish to use before I am
placed on Military Leave Without Pay: Amount of compensatory time in days available: Amount of compensatory time in days I wish to use
before I am placed on Military Leave Without Pay: Number of other leave days available (specify): Number of other leave days I wish to use before I am
placed on Military Leave Without Pay:
Upon the exhaustion of any available Statutory Entitlement, I elect not to use any Leave Balances. I understand that my approved leave of absence will continue, but that I shall be placed on Military Leave Without Pay.
Employee Name (Please Print)
Employee ID
Employee Signature
Date
DP-2532 r12/2010
REEMPLOYMENT RIGHTS
The Uniformed Services Employment and Reemployment Rights Act of 1994, Section 4312, Subsections (a), (b), and (c) states the Reemployment rights of persons who serve in the uniformed services. Subsection (a) (2) reads as follows: “The cumulative length of the absence and of all previous absences from a position of employment with that employer by reason of service in the uniformed services does not exceed five years.” Exceptions to the 5 year limit are listed in Section 4312, subsection (c)
I have been informed that I must report after separation to claim my position as an employee of the New York City Police Department as follows:
a) Period of service in the uniformed services was less than 31 days, must report not later than the beginning of the first full regularly scheduled work period on the first full calendar day following the completion of the period of service.
b) Period of service in the uniformed services was for more than 30 days but less than 181 days; must report no later than 14 days after completion of the period of service.
c) Period of service in the uniformed services was for more than 180 days; must report no later than 90 days after the completion of the period of service.
I realize that failure to comply with the above may result in the termination of my employment.
I further understand that the maximum of five (5) years of voluntary military service will be cumulatively calculated during the total period of Departmental Service.
I understand that upon reporting to claim my position as an employee of the NYC Police Department, that I will immediately commence employment.
I fully understand the contents of this statement.
_______________________________ ___________________ Signature Date (mm/dd/yyyy) _______________________________ ___________________
Tax # Name Printed
LJ INSTRUCTIONS: All Copies Should Accompany Member of the Service Appearing at the NYC Police Pension Fund
PROPERTY RECEIPT - DISCONTINUANCE OF SERVICE PD 520-013 (Rev. 05-09)
Name (Printed Last, First, MI)
Date of Appointment Command
Last Four Digits Of Soc. Sec. No.
Tax Reg . No.
Member is 0 SERVICE RETIREMENT 0 DISABILITY RETIREMENT 0 VESTED INTEREST Applying For: 0 RESIGNATION 0 EXTENDED LEAVE OF ABSENCE (30 days or more) 0 WITHOUT PAY
DEPARTMENT EQUIPMENT DISPOSITION (Use Boxes' 13 15 For Equipment ReturnfJd Not Listed Below) -ITEM RECEIVED BY (Printed) SIGNATURE COMMAND
1. SHIELD
2. I.D. CARD
3. O.C. PEPPER SPRAY NUMBER:
4. HELMET
5. NEW YORK CITY TRANSIT POLICE PASS METRO CARD
6. LlRR POLICE PASS
7. METRO-NORTH RR POLICE PASS
8. DEPARTMENT Communications Division, Telecommunications Unit,
. I
CELL PHONE One Police Plaza, Room 910B
9. RESTRICTED/HQ ANNEX PARKING PERMIT
10. NYPD VEHICLE IDENTIFICATION PLATE
11. DEPARTMENT RADIO
12. LAPTOP COMPUTER (CAPTAINS AND ABOVE)
13.
14.
15.
~t ' . . y. %
" FIREARMS P(2)SSESSED BY MEMBER
CALIBER MAKE MODEL TYPE SERIAL NO.
Unused Summonses Returned? D YES o NO Charges Pending? DYES o NO Next Scheduled Tour After Signature of Commanding Officer Leaves, Except Terminal Leave:
'" r · "- ' ~" ,, ·c
FOR NYC POLICE PENSION FUND USE O~LY Date Filed
LWOP Ends Date Property To Be Turned In:
Disposition Of Firearms If Not Delivered To Property Clerk
WAIVER TO BEGIN T.L
Remarks:
o APPROVED o DISAPPROVED
PREPARED RanklTitle BY:
Rank, Name, Command
Name Printed Signature
' 3
i, ... ; .. VOUCHER NO.
.......
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