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Reduced Annual Salary Deductions Total Unadjusted Take Home Approximate PART IV - APPROVAL D LEAVE ARRANGEMENT APPROVED leave arrangement D Duration ofaveraging period 12 month From To D I certify that the employee meets the eligibility criteria Responsibility Centre Manager print name TBS 325-10E Rev. 1999-05-18 Once completed provide employee with a photocopy. Treasury Board of Canada Secretariat Secr tariat du Conseil du Tr sor du Canada PROTECTED WHEN COMPLETED APPLICATION FOR LEAVE WITH INCOME AVERAGING Information on this form is used to assess requests for Leave with Income Averaging in accordance with approved policies. It is protected by the provisions of the Privacy Act and should be stored in standard employee bank PSE 901. PART I - EMPLOYEE DATA Surname Print Department Given name / Initials Branch / Division / Section Personal Record Identifier Address PART II - APPLICATION Duration 1st period of leave FROM TO 2nd period of leave Date I request a leave arrangement in accordance with the Leave with Income Averaging Policy. I agree not to work for the federal Public Service during the above period s of leave. Day Month Year Signature PART III - ESTIMATED SALARY to be completed by Compensation Unit Current Annual Salary and Allowances Bi-weekly amount Deductions Net Take Home approximate Less leave without pay There will be some adjustments in respect of certain statutory deductions such as Income Tax CPP/QPP UI and you may be able to adjust some voluntary deductions such as CSB and CO-OP. Treasury Board of Canada Secretariat Secr tariat du Conseil du Tr sor du Canada PROTECTED WHEN COMPLETED APPLICATION FOR LEAVE WITH INCOME AVERAGING Information on this form is used to assess requests for Leave with Income Averaging in accordance with approved policies. It is protected by the provisions of the Privacy Act and should be stored in standard employee bank PSE 901. It is protected by the provisions of the Privacy Act and should be stored in standard employee bank PSE 901. PART I - EMPLOYEE DATA Surname Print Department Given name / Initials Branch / Division / Section Personal Record Identifier Address PART II - APPLICATION Duration 1st period of leave FROM TO 2nd period of leave Date I request a leave arrangement in accordance with the Leave with Income Averaging Policy. PART I - EMPLOYEE DATA Surname Print Department Given name / Initials Branch / Division / Section Personal Record Identifier Address PART II - APPLICATION Duration 1st period of leave FROM TO 2nd period of leave Date I request a leave arrangement in accordance with the Leave with Income Averaging Policy. I agree not to work for the federal Public Service during the above period s of leave. Day Month Year Signature PART III - ESTIMATED SALARY to be completed by Compensation Unit Current Annual Salary and Allowances Bi-weekly amount Deductions Net Take Home approximate Less leave without pay There will be some adjustments in respect of certain statutory deductions such as Income Tax CPP/QPP UI and you may be able to adjust some voluntary deductions such as CSB and CO-OP.

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