Request to Donate Annual Leave to Leave Recipient Under the Voluntary Leave Transfer Program Outside 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 end of last pay period 8. Amount of leave projected to forfeit this leave year as of end of last pay period 9. Amount of annual leave to be transferred 10. Leave recipient's name, agency, agency's address, organization (Agency, Department, Office, Division, Branch, etc.) 11a. Leave donor's signature 11b. 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 credited to the leave recipient's annual leave account 13. If the agency is waiving the maximum limitations for leave donation under the voluntary leave transfer program, describe the special circumstance that warrants the waiver 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 American LegalNet, Inc. www.FormsWorkFlow.com OPM 630-B August 2013 Formerly Optional Form (OF) 630-B