Application to Become a Leave Recipient
Under the Emergency Leave Transfer Program
Completed Form Must Be Submitted To Employing Agency
1. Applicant's name
(Last, first, middle)
2. Employee or SSN (last 4 digits)
3a. Position title 3b. Pay plan 3c. Grade/pay level
4. Name of organization
(Agency, Department, Office, Division, Branch, etc.)
5. Office telephone number
6. Major disaster or emergency declared by the President
7. Nature and severity of the emergency as it relates to the applicant
8. Individual affected by the emergency
9. Date emergency began 10. Date emergency ended
(check one) (or is expected to end)
Employee
Employee's family member
11a. Name of individual completing application 11b. Relationship to applicant 11c. Telephone number (area code)
(If applying on behalf of the applicant)
12a. I certify that the above statements are true. 12b. Date signed
(Signature of applicant or individual applying on behalf of applicant)
Privacy Act Statement
Participation in this program is voluntary; however, solicitation of this information is authorized under 5 U.S.C. 6391. The information furnished
will be used to identify records properly associated with the transfer of annual leave. It may also be disclosed to a national, State, or local law
enforcement agency where there is an indication of a violation or potential violation of civil or criminal law, rule, or regulation; or to another
agency or court when the Government is party to a suit. Public Law 104-134 (April 26, 1996) requires that any person doing business with the
Federal Government furnish a social security number or tax identification number. This is an amendment to title 31, Section 7701. Furnishing
the social security number, as well as other data, is voluntary, but failure to do so may delay or prevent action on the application. If your
agency uses the information furnished on this form for purposes other than those indicated above, it may provide you with an additional
statement reflecting those purposes.
13. First level supervisor's recommendation 14. Deciding official's decision
Approve
Disapprove
Approve
Signature
Disapprove
Date signed Signature Date signed
Office of Personnel Management
5 CFR 630
Local Reproduction Authorized
OPM 1637
Revised August 2013
Previous editions are usable
click to sign
signature
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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