Request to Donate Annual Leave Under the
Emergency Leave Transfer Program
I request that my annual leave be transferred to the emergency leave transfer program established by the Office of Personnel Management.
As of the date indicated below, I have enough annual leave in my account to cover this amount. I understand I may not donate more than
104 hours of annual leave under the emergency leave transfer program, unless otherwise permitted by my agency.
I understand that my decision to transfer leave is not revocable. If a sufficient balance of unused donated leave remains after the emergency
has terminated, I understand that a pro-rated share will be returned to me either during the current leave year or the following leave year.
However, to recredit my leave, I must remain employed by a Federal agency and be subject to chapter 63 of title 5, United States Code. I
have not been directly or indirectly intimidated, threatened or coerced, or promised any benefit by an employee for the purpose of donating
or using leave.
Completed Form Must Be Submitted to Employing Agency
1. Applicant's name
(Last, first, middle)
2. Employee or 661ODVWGLJLWV
Pay plan 3c. Grade/pay level 3a. Position title 3b.
4. Name of organization
(Agency, Department, Office, Division, Branch, etc.)
5. Office telephone number
6. Amount of annual leave accrued as of end of last pay period 7. Amount of annual leave to be donated
8. Major disaster or emergency declared by the President
9a. Signature 9b. Date signed
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.
Office of Personnel Management
5 CFR 630
Local Reproduction Authorized
OPM 1638
Revised August 2013
Previous editions are usable
click to sign
signature
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