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 (check one) Employee Employee's family member 11a. Name of individual completing application (If applying on behalf of the applicant) 9. Date emergency began 10. Date emergency ended (or is expected to end) 11b. Relationship to applicant 11c. Telephone number (area code) 12a. I certify that the above statements are true. (Signature of applicant or individual applying on behalf of applicant) 12b. 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. 13. First level supervisor's recommendation Approve Signature Disapprove Date signed 14. 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 1637 Revised August 2013 Previous editions are usable