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<tbody>
<tr class="odd">
<td colspan="10" rowspan="2"><strong>LEAVE TRANSFER PROGRAM - DONOR
APPLICATION</strong></td>
<td colspan="3"><p><strong>FOR PERSONNEL USE ONLY:</strong></p>
<p><strong>CASE NUMBER</strong></p></td>
</tr>
<tr class="even">
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="13"><strong>INSTRUCTIONS:</strong> Use this form to request
the transfer of earned annual leave to an approved leave recipient under
P.L. 100-566. You may not transfer leave to your immediate supervisor.
After completion, forward it to the office in your agency designated to
approve leave donations.</td>
</tr>
<tr class="even">
<td colspan="13"><strong>PART I - COMPLETED BY DONOR</strong></td>
</tr>
<tr class="odd">
<td colspan="6">1. NAME OF DONOR <em>(Last, First, Middle
Initial)</em></td>
<td colspan="7">2. POSITION TITLE</td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td colspan="4">3. SOCIAL SECURITY NUMBER</td>
<td colspan="2">4. SERIES, GRADE, OR PAY LEVEL</td>
<td colspan="7">5. ORGANIZATIONAL TITLE <em>(Agency, Division, Branch
Section)</em></td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td colspan="10">6. OFFICE ADDRESS</td>
<td colspan="3">7. OFFICE TELEPHONE NO.</td>
</tr>
<tr class="even">
<td colspan="10">     </td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="4">8. NAME OF TIMEKEEPER</td>
<td colspan="2">9. TELEPHONE NO. OF TIMEKEEPER</td>
<td colspan="7">10. OFFICE ADDRESS OF TIMEKEEPER</td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td colspan="13"><p><strong>INSTRUCTIONS:</strong> Please review the
information below. You may not transfer more than 1/2 of the annual
leave you will earn during this calendar year unless a waiver is
approved. To request a waiver, you must attach a statement as to why
your situation is unusual.</p>
<p>If you will be employed full-time by the federal government for the
full calendar year, the limits are as follows:</p>
<p>• 52 hours for employees in the 4-hour leave earning category.</p>
<p>• 78 hours for employees in the 6-hour leave earning category, or</p>
<p>• 104 hours for employees in the 8-hour leave earning category.</p>
<p>If you are a part-time employee or if you will not be employed for
the full calendar year, you may compute your transfer limit using the
appropriate formula below:</p></td>
</tr>
<tr class="even">
<td colspan="4">$ Limit for part-time employee = <strong>13
X</strong></td>
<td colspan="5">Duty hours in Pay Period</td>
<td colspan="4"><strong>X</strong> leave earning category</td>
</tr>
<tr class="odd">
<td colspan="4">    </td>
<td colspan="5"><strong>80</strong></td>
<td colspan="4"> </td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="5"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="4">$ Limit for part-year employee =</td>
<td colspan="5">Number of Pay Periods to be worked</td>
<td colspan="4"><strong>X</strong> leave earning category</td>
</tr>
<tr class="even">
<td colspan="4">    </td>
<td colspan="5"><strong>2</strong></td>
<td colspan="4"> </td>
</tr>
<tr class="odd">
<td colspan="4"><p>11. NUMBER OF HOURS OF ANNUAL</p>
<p>LEAVE TO BE TRANSFERRED</p></td>
<td colspan="3">12. NAME OF RECIPIENT</td>
<td colspan="4">13. CASE NUMBER</td>
<td colspan="2"><p>14. SOCIAL SECURITY NUMBER</p>
<p>OF RECIPIENT <em>(if known)</em></p></td>
</tr>
<tr class="even">
<td colspan="4">   </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="7">15. ORGANIZATIONAL LOCATION OF RECIPIENT <em>(Agency,
Division, Branch, Section)</em></td>
<td colspan="6">16. OFFICE ADDRESS OF RECIPIENT</td>
</tr>
<tr class="even">
<td colspan="7">     </td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="4">17. NAME OF LEAVE SHARE COORDINATOR</td>
<td colspan="3"><p>18. TELEPHONE NO. OF LEAVE SHARE</p>
<p>COORDINATOR</p></td>
<td colspan="6">19. OFFICE ADDRESS OF LEAVE SHARE COORDINATOR</td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="13"><strong>CERTIFICATION OF VOLUNTARY DONATION:</strong>
<em>I certify that I am making this donation entirely of my own free
will and that no attempts have been made to coerce me to donate annual
leave. I understand that except for any leave unused by the recipient, I
have no right under my circumstances (including a medical emergency of
my own) to have any of the donated leave restored.</em></td>
</tr>
<tr class="even">
<td colspan="11" rowspan="2">SIGNATURE OF DONOR</td>
<td colspan="2">DATE</td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="13"><strong>PART II - AGENCY REVIEW AND
APPROVAL</strong></td>
</tr>
<tr class="odd">
<td colspan="4">1. CURRENT ANNUAL LEAVE BALANCE <em>(in hours)</em></td>
<td colspan="3">AS OF PAY PERIOD NUMBER</td>
<td colspan="6">2. ANNUAL LEAVE CATEGORY PER PAY PERIOD</td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="3">  </td>
<td colspan="6"> </td>
</tr>
<tr class="odd">
<td colspan="13"><strong>APPLICATION APPROVED:</strong></td>
</tr>
<tr class="even">
<td></td>
<td>YES</td>
<td colspan="11">(This application meets all criteria required for
annual leave transfer by law, regulation and Department policy.</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9">Transferred leave may be credited to the recipient's
account effective Pay Period Number):</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td>NO</td>
<td><p><em>(state reason</em></p>
<p><em>for disapproval):</em></p></td>
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td colspan="5">SIGNATURE OF APPROVING OR DISAPPROVING OFFICIAL</td>
<td colspan="3">TITLE</td>
<td colspan="4">OFFICE TELEPHONE NO.</td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="13"><strong>PRIVACY ACT STATEMENT</strong></td>
</tr>
<tr class="even">
<td colspan="13">§ U.S.C. 6311 authorizes collection of this
information. Your social security number is requested solely for the
purpose of positively identifying leave donors so that donated leave can
be deducted from the proper account. Although the disclosure of this
information is voluntary, failure to furnish this information may result
in disapproval of this application.</td>
</tr>
<tr class="odd">
<td colspan="13"><p><strong>AD-1043</strong></p>
<p><strong>(Rev. 4/89)</strong></p></td>
</tr>
</tbody>
</table>