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 of organization (Agency, Department, Office, Division, Branch, etc.) 6. Office telephone number 7. Nature and severity of the medical emergency 8. Individual affected by medical emergency 9. Date medical emergency began (check one) Employee Employee's family member 10. Date medical emergency ended (or is expected to end) 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 balance Sick leave balance Hours 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 (If applying on behalf of the applicant) 15b. Relationship to applicant 15c.Telephone number (area code) 16a. I certify that the above statements are true. (Signature of applicant or individual applying on behalf of applicant) 16b. 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. 17. First level supervisor's recommendation Approve Signature Disapprove Date signed 18. Deciding official's decision Approve Signature Disapprove Date signed Office of Personnel Management 5 CFR 630 Local Reproduction Authorized American LegalNet, Inc. www.FormsWorkFlow.com OPM 630 June 2001 Formerly Optional Form (OF) 630