1 Request to Donate Annual Leave to Leave Recipient Within Agency Under the Voluntary Leave Transfer Program I request that annual leave be transferred to the leave account of an approved leave recipient. This recipient is not my immedi ate 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 ho urs remaining in the leave year for which I am scheduled to work. The amount of annual leave I am transferring also is not more tha n 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 leave remains after the rec ipient'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 employed following leave year, or I can elect to donate my pro-rated share to another leave recipient. However, to do so, I must remain 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 purp ose of donating or using leave. To Be Completed By Leave Donor (Last, first, middle) 2. SSN (last 4 digits) 3. Employee Number 1. Name 4a. Position title 4b. Pay plan 4c. Grade/pay level 5b. Office telephone number 5a. Name of organization (Agency, Department, Office, Division, Branch, etc.) 6. Amount of annual leave accrued as of 7. Amount of leave projected to forfeit this 8. Amount of annual leave to be transferred leave year as of end of last pay period end of last pay period 9. Individual's name or identification number to whom leave is being donated 10b. Date signed 10a. Signature Privacy Act Statement Participation in this program is voluntary; however; solicitation of this information is authorized under 5 U.S.C 6332. The inf ormation 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, ru le, 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 tit le 31, Section 7701. Furnishing the social security number, as well as other data, is voluntary, but failure to do so may delay or pre vent action on the application. If your agency uses the information furnished on this form for purposes other than those indicated above, it m ay provide you with an additional statement reflecting those purposes. OPM 630-A Local Reproduction Authorized Office of Personnel Management August 2013 5 CFR 630 Formerly Optional Form (OF) 630 A

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