Election-Worker Service Leave Request and Appointing-Authority Certification Packet - Indiana

PRECINCT-ELECTION-OFFICER PAID-LEAVE REQUEST AND APPOINTMENT CERTIFICATION

Indiana — Ind. Code §§ 3-5-2.1-82 and 3-5-4-15

This packet is for the narrow local-government paid-leave route in Ind. Code § 3-5-4-15. It is separate from time off to vote.

1. EMPLOYEE AND LOCAL GOVERNMENT OFFICE

Covered employing office:

• ☐ County office
• ☐ City office
• ☐ Town office
• ☐ Township office

• ☐ School office

• ☐ Employer confirms that the employee works for a “local government office” as defined in Ind. Code § 3-5-4-15(a).

State agencies, private employers, and other entities are not automatically included in that definition.

2. PRECINCT-ELECTION-OFFICER APPOINTMENT

Appointing authority: [________________________________]

County / precinct: [________________________________]

Appointed role under Ind. Code § 3-5-2.1-82:

• ☐ Inspector
• ☐ Judge
• ☐ Poll clerk
• ☐ Assistant poll clerk
• ☐ Election sheriff

Appointment date: [__/__/____]

Appointment notice attached: ☐ Yes ☐ No

• ☐ The appointing authority confirms that the employee was appointed to serve in a precinct in the role marked above.

3. ELECTION-DAY PAID-LEAVE REQUEST

Election:

• ☐ Primary election day — [DATE]
• ☐ General election day — [DATE]

Expected precinct service hours: [________________________________]

Expected overlap with scheduled work: [________________________________]

Employee request:

I request a paid day of leave under Ind. Code § 3-5-4-15 to serve as an appointed precinct election officer on the primary election day or general election day identified above.

Request delivered on: [__/__/____]

Delivery method / recipient: [________________________________]

Employee signature: __________________________ Date: ______________

Section 3-5-4-15 does not state a minimum advance-notice period. Operational notice may be documented without treating an employer-created deadline as part of the statute.

4. APPOINTING-AUTHORITY CERTIFICATION

I certify that [EMPLOYEE] was appointed to serve in the precinct-election-officer role and on the election date identified above.

Authorized signature: _________________________ Date: ______________

Printed name / title: [________________________________]

5. PUBLIC-SAFETY OR ELECTION-OPERATIONS EXCEPTION

The paid-leave requirement does not apply if the requesting employee's duties are necessary for public safety or election-day operations.

• ☐ The employee's duties are not necessary for either statutory purpose; proceed to paid-leave review.
• ☐ The employee's duties are asserted to be necessary for public safety.
• ☐ The employee's duties are asserted to be necessary for election-day operations.
• ☐ Counsel / labor-relations review is required before relying on the exception.

Specific duties and operational facts: [________________________________]

Decision-maker: [________________________________]

6. PAID-LEAVE AND ELECTION-COMPENSATION RECORD

If the exception does not apply, § 3-5-4-15 requires a paid day of leave. The employee granted that leave is also entitled to receive compensation for serving as a precinct election officer.

• ☐ Paid day of leave approved.
• ☐ Election-officer compensation will not be treated as replacing the statutory paid leave.
• ☐ Any proposed offset or remittance was referred for Indiana-counsel review.

7. EXCLUDED OR SEPARATELY GOVERNED TIME

Section 3-5-4-15 addresses service on primary election day or general election day. It does not state a paid-leave rule for training, travel, application, early voting, a special election, or another day.

8. EMPLOYER DECISION AND POST-SERVICE CLOSEOUT

• ☐ Covered local-government office confirmed.
• ☐ Qualifying appointment and role confirmed.
• ☐ Primary or general election-day service confirmed.
• ☐ Paid day of leave approved.
• ☐ Statutory operational exception documented and reviewed.

Employer representative: _____________________ Date: ______________

Decision delivered: [DATE / METHOD]

Actual service date and hours: [________________________________]

Service certification received: [__/__/____]

Payroll correction, if any: [________________________________]

OFFICIAL SOURCES VERIFIED

• Indiana General Assembly — 2026 Ind. Code ch. 3-5-2.1
• Indiana General Assembly — 2026 Ind. Code ch. 3-5-4