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<tr class="odd">
<td colspan="27"><strong>This form is available
electronically.</strong></td>
</tr>
<tr class="even">
<td colspan="23" rowspan="2"><strong>LEAVE TRANSFER PROGRAM - RECIPIENT
APPLICATION</strong></td>
<td colspan="4"><p><strong>FOR PERSONNEL USE ONLY:</strong></p>
<p><strong>CASE NUMBER</strong></p></td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="27"><strong>INSTRUCTIONS:</strong> Use this form to apply
to be a leave recipient under P.L. 100-566. Attach to this form a brief
description of the nature and severity of the medical emergency
<u>and</u> appropriate documentation of the medical emergency: a
physician's certificate, the medical prognosis and anticipated duration
of the condition. After completing this form, forward through your
supervisor to the office in your agency designated to approve leave
recipients. <strong>Approval as a leave recipient does not guarantee
that leave will be donated. Donor employees will designate the recipient
of their leave.</strong></td>
</tr>
<tr class="odd">
<td colspan="27"><strong>PART I - APPLICATION AND CERTIFICATION
(</strong><em>To be completed by the applicant or another employee on
his or her behalf)</em></td>
</tr>
<tr class="even">
<td colspan="12">1. NAME OF RECIPIENT <em>(Last, First, Middle
Initial)</em></td>
<td colspan="11">2. POSITION TITLE</td>
<td colspan="4">3. SOCIAL SECURITY NUMBER</td>
</tr>
<tr class="odd">
<td colspan="12">     </td>
<td colspan="11">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="8">4. SERIES, GRADE OR PAY LEVEL</td>
<td colspan="4">5. DUTY STATION</td>
<td colspan="15">6. ORGANIZATIONAL TITLE <em>(Agency, Division, Branch
Section)</em></td>
</tr>
<tr class="odd">
<td colspan="8">     </td>
<td colspan="4">     </td>
<td colspan="15">     </td>
</tr>
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<td colspan="10">7. OFFICE ADDRESS</td>
<td colspan="2"></td>
<td colspan="11">8. OFFICE TELEPHONE NO.</td>
<td colspan="4">9. HOME TELEPHONE NO.</td>
</tr>
<tr class="odd">
<td colspan="12">     </td>
<td colspan="11">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="8">10. NAME OF TIMEKEEPER</td>
<td colspan="12">11. TELEPHONE NO. OF TIMEKEEPER</td>
<td colspan="7">12. OFFICE ADDRESS OF TIMEKEEPER</td>
</tr>
<tr class="odd">
<td colspan="8">     </td>
<td colspan="12">     </td>
<td colspan="7">    </td>
</tr>
<tr class="even">
<td colspan="8">13. T&amp;A CONTACT POINT NO.</td>
<td colspan="12"><p>14. ANTICIPATED OR ACTUAL</p>
<p>DURATION OF MEDICAL</p>
<p>EMERGENCY (if known)</p></td>
<td colspan="4"><p>15. DATES LEAVE</p>
<p>EXHAUSTED</p></td>
<td colspan="3"><p>16. AMOUNT OF DONATED LEAVE</p>
<p>REQUESTED <em>(hours, days or</em></p>
<p><em>months)</em></p></td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="2">     </td>
<td colspan="6">Beginning Date:</td>
<td colspan="6">Ending Date:</td>
<td colspan="2">Annual:</td>
<td colspan="2">Sick <em>(if applicable</em>):</td>
<td colspan="3" rowspan="2">   </td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="6">     </td>
<td colspan="2">    </td>
<td colspan="2">    </td>
</tr>
<tr class="odd">
<td colspan="24">17. PLEASE INDICATE HOW YOU PREFER THE ANNUAL LEAVE
DONATED TO BE APPLIED BY NUMBERING THE FOLLOWING IN ORDER OF YOUR
PREFERENCE. <em>(Donated annual leave may be applied to retroactively
replace leave without pay and/or advanced sick or annual leave in
connection with this medical emergency.)</em></td>
<td colspan="3">PLEASE INDICATE PAY PERIOD DONATED ANNUAL LEAVE MAY BE
RETROACTIVELY APPLIED</td>
</tr>
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<td colspan="2">   </td>
<td colspan="4">For current use</td>
<td>   </td>
<td colspan="4"><p>against advanced</p>
<p>annual leave</p></td>
<td>   </td>
<td colspan="5"><p>against advanced</p>
<p>sick leave</p></td>
<td colspan="2">   </td>
<td colspan="5">against LWOP</td>
<td colspan="3">   </td>
</tr>
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<td colspan="27"></td>
</tr>
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<td colspan="8">18. I agree to have my <em>(please specify)</em></td>
<td colspan="2"></td>
<td colspan="5">case number only</td>
<td colspan="3"></td>
<td colspan="5">case number, and circumstances only</td>
<td colspan="2"></td>
<td colspan="2">name, case number and circumstances</td>
</tr>
<tr class="odd">
<td colspan="27">published for the purpose of receiving donations. If I
agree to have my circumstances published, the following 5 lines or less
describing my medical emergency will be published exactly as I write it
and will be published exactly as I write made available to employees of
my agency who which to make donations to me.</td>
</tr>
<tr class="even">
<td colspan="27" rowspan="2">     </td>
</tr>
<tr class="odd">
</tr>
<tr class="even">
<td colspan="27"><p>CERTIFICATION <em>(If certifying on behalf of
another employee, modify as appropriate.)</em></p>
<p>I certify that (1) I have been affected by the medical emergency
described in the attachment since the date indicated above, (2) I have
or will have exhausted all annual leave and any available sick leave
that could otherwise be used as of date indicated above, and (3) expect
to be absent from duty without paid leave at least 80 hours because of
this medical emergency. I further certify that I am not receiving
unemployment benefits or workers' compensation benefits in connection
with this medical emergency for which I am requesting transferred annual
leave.</p></td>
</tr>
<tr class="odd">
<td colspan="23">SIGNATURE OF RECIPIENT OR HIS OR HER DESIGNEE
<em>(please specify)</em>:</td>
<td colspan="4">DATE</td>
</tr>
<tr class="even">
<td></td>
<td colspan="4">Recipient</td>
<td colspan="18"></td>
<td colspan="4" rowspan="2">     </td>
</tr>
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<td></td>
<td colspan="4">Designee</td>
<td colspan="18"></td>
</tr>
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<td colspan="8">CONCURRENCE: SIGNATURE OF SUPERVISOR</td>
<td colspan="8">TITLE</td>
<td colspan="7">OFFICE TELEPHONE NO.</td>
<td colspan="4">DATE</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">Yes</td>
<td colspan="5"></td>
<td colspan="8" rowspan="2">     </td>
<td colspan="7" rowspan="2">     </td>
<td colspan="4" rowspan="2">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">No</td>
<td colspan="5"></td>
</tr>
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<td colspan="27"><strong>PART II - AGENCY REVIEW AND
APPROVAL</strong></td>
</tr>
<tr class="even">
<td colspan="5"><p>1. CURRENT ANNUAL</p>
<p>LEAVE BALANCE</p>
<p><em>(in hours)</em></p></td>
<td colspan="3"><p>2. CURRENT SICK</p>
<p>LEAVE BALANCE</p>
<p><em>(in hours)</em></p></td>
<td colspan="5"><p>3. LWOP HOURS USED</p>
<p>IN CONJUNCTION</p>
<p>WITH THIS</p>
<p>EMERGENCY</p></td>
<td colspan="6"><p>4. ADVANCED SICK</p>
<p>LEAVE HOURS TO</p>
<p>DATE</p></td>
<td colspan="6"><p>5. ADVANCED ANNUAL</p>
<p>LEAVE HOURS TO DATE</p></td>
<td colspan="2"><p>6. ANNUAL LEAVE CATEGORY</p>
<p>PER PAY PERIOD</p></td>
</tr>
<tr class="odd">
<td colspan="5">    </td>
<td colspan="3">    </td>
<td colspan="5">    </td>
<td colspan="6">    </td>
<td colspan="6">    </td>
<td colspan="2"> </td>
</tr>
<tr class="even">
<td colspan="27"><strong>APPLICATION APPROVED:</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">Yes</td>
<td colspan="21"><em>(If Yes, transferred leave may be credited to the
recipient's account effective Pay Period Number):</em></td>
<td>  </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">No</td>
<td colspan="5"><em>(state reason for disapproval):</em></td>
<td colspan="18">     </td>
</tr>
<tr class="odd">
<td colspan="9">SIGNATURE OF APPROVING OR DISAPPROVING OFFICIAL</td>
<td colspan="10">TITLE</td>
<td colspan="6">OFFICE TELEPHONE NO.</td>
<td colspan="2">DATE</td>
</tr>
<tr class="even">
<td colspan="9"></td>
<td colspan="10">     </td>
<td colspan="6">     </td>
<td colspan="2">     </td>
</tr>
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<td colspan="27"><strong>PRIVACY ACT STATEMENT</strong></td>
</tr>
<tr class="even">
<td colspan="27">§ U.S.C. 6311 authorizes collection of this
information. Your social security number may be disclosed to leave
donors for the purpose of positively identifying leave recipients so
that donated leave can be credited to the proper account.</td>
</tr>
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<td colspan="21"></td>
<td colspan="6"><p><strong>AD-1046</strong></p>
<p><strong>REV(4-89)</strong></p></td>
</tr>
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</table>