Application to Become a Leave Recipient
Under the Voluntary Leave Transfer Program
1. Applicant's name (Last, first, middle)
2. SSN (last 4 digits) 3. Employee Number
4a. Position title 4b. Pay plan 4c. Grade/pay level
5. Name organization (Agency, Division, Branch, etc.)
6.
of Department, Office,
Office telephone number
7. Nature and severity of the medical emergency
8. Individual affected by medical emergency 9. Date medical emergency began 10. Date medical emergency ended
(check one) (or is expected to end)
Employee
Employee's family member
11. Name of physician who will verify the medical emergency. (Attach documentation from the physician (or other appropriate expert)
showing the diagnosis, prognosis and duration of illness.)
12. What is the applicant's annual and sick leave balances as of end of last pay period? 13. How many hours of leave without pay have
been used for this medical emergency?
Annual leave
Sick leave
balance
Hours
balance
14. Provide a description of the medical emergency to be distributed to servicing personnel offices so that other employees may
donate annual leave to the applicant.
Description of medical emergency
Check box if applicant does not want a description distributed.
Check box if applicant does not wish to have name used with the description
or disclosed to anyone except the supervisor, the supervisory channel and
the deciding official, and individuals who maintain the program.
15a. Name of individual completing application 15b. Relationship to applicant 15c.Telephone number (area code)
(If applying on behalf of the applicant)
16a. I certify that the above statements are true. 16b. 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. 6332. 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.
17. First level supervisor's recommendation 18. Deciding official's decision
Approve
Disapprove Disapprove
Signature Date signed
Signature
Date signed
Approve
Office of Personnel Management
5 CFR 630
Local Reproduction Authorized
OPM 630
June 2001
Formerly Optional Form (OF) 630
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