Request to Donate Annual Leave to Leave Recipient
Outside
Under the Voluntary Leave Transfer Program
Agency
I request that annual leave be transferred to the leave account of an approved leave recipient. This recipient is not my immediate
supervisor. As of the date indicated below, I have enough annual leave in my account to cover this amount. I understand that if I am
projected to forfeit annual leave during this leave year, the amount of leave I am transferring may not exceed the number of hours
remaining in the leave year for which I am scheduled to work. The amount of annual leave I am transferring also is not more than half the
hours I will earn this year.
I understand that my decision to transfer leave is not revocable. If a sufficient balance of unused donated leave remains after the
recipient's medical emergency has terminated, I can elect to have a pro-rated share returned to me during either the current leave year
or the following leave year, or I can elect to donate my pro-rated share to another leave recipient. However, to do so, 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 any employee for the purpose of donating or using leave.
Part A - To Be Completed By Leave Donor
1. Name
(Last, first, middle)
2. SSN (Last 4 digits) 3. Employee Number
4a. Position title
4b. Pay plan 4c. Grade/pay level 5. Relationship of leave donor to leave recipient
(if any)
6. Leave donor's agency
(Agency, Department, Office, Division, Branch, etc.)
7. Amount of annual leave accrued as of 8. Amount of leave projected to forfeit this 9. Amount of annual leave to be transferred
end of last pay period leave year as of end of last pay period
10. Leave recipient's name, agency, agency's address, organization
(Agency, Department, Office, Division, Branch, etc.)
signature 11b.11a. Leave donor's Date signed
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.
Part B - To Be Completed By Employing Agency of Leave Donor
Upon completion and approval of this form, forward a copy to the leave recipient's employing agency as soon as possible so that the
transfer of leave can take place.
12. Enter the amount of annual leave to be 13. If the agency is waiving the maximum limitations for leave donation under the voluntary
credited to the leave recipient's annual leave transfer program, describe the special circumstance that warrants the waiver
leave account
14a. Name of agency contact who can provide further information 14b. Telephone number
15. Certification:
I certify that the leave donor currently has sufficient annual leave in his/her annual leave account to make a donation of the
requested amount of annual leave and that the amount of the donation does not exceed the maximum limitations for leave donation under
the voluntary leave transfer program.
15a. Signature of authorizing official 15b. Date Signed
Office of Personnel Management
5 CFR 630
Local Reproduction Authorized OPM 630-B
August 2013
Formerly Optional Form (OF) 630-B
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