REQUEST FOR RESTORATION OF FORFEITED ANNUAL LEAVE

(See information on reverse before completing this form.)

PRIVACY ACT STATEMENT

1. REASON

INSTRUCTIONS:

Submit original. 

DATE OF REQUEST

FROM (Typed or printed name of employee) OFFICE SYMBOL TELEPHONE EXTENSION

SECTION I - BASIS FOR RESTORATION (To be completed by employee. X applicable block and provide justification below.)

a. ADMINISTRATIVE ERROR b. SICKNESS c. EXIGENCY OF PUBLIC BUSINESS 

2. JUSTIFICATION

SECTION II - SUPERVISOR'S STATEMENT

12. NAME 13. ORGANIZATIONAL TITLE 14. SERIES 15. GRADE

3. DATE LEAVE REQUESTED 4. BEGINNING DATE OF LEAVE 5. ENDING DATE OF LEAVE

6. AMOUNT OF LEAVE REQUESTED 7. DATE LEAVE APPROVED 8. DATE LEAVE CANCELLED

9. DATES OF CANCELLED LEAVE (List)

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USE(S):

DISCLOSURE:

10 U.S.C. 136; EO 9397, November 1943 (SSN).

Used to compute and control leave usage and leave balances.

Information may be disclosed for any of the DLA blanket routine uses.

Voluntary. However, failure to provide all the requested information may result in disapproval of restoration request.

DLA PRIVACY ACT SYSTEM NOTICE S434.15 applies.

DLA FORM 1868, MAY 2003 (EG) Previous edition is obsolete.

17. EFFORTS MADE TO RESCHEDULE LEAVE PRIOR TO THE END OF THE LEAVE YEAR (Provide chronology of all subsequent requests, approvals, and

cancellations)

10. AMOUNT OF LEAVE FORFEITED 11. DATE OF ENDING OF EXIGENCY OR ILLNESS

NOTE: OPM 71, APPLICATION FOR LEAVE, OR OTHER DOCUMENTS MUST BE ATTACHED TO SUPPORT ITEMS 3 - 9.

16. REASON FOR CANCELLATION OF LEAVE

a. SIGNATURE b. DATE

18. I have reviewed all parts and written documentation and recommend approval. I CERTIFY I have carried out my responsibilities as indicated on back of form.

PDF (DLA)

TO 
19. I CERTIFY that the operational demands or requirements stated in this request were of such magnitude or significance that the employee could not

be excused from duty to avoid forfeiture of scheduled annual leave.

SECTION III - OFFICIAL DETERMINING EXIGENCY OF PUBLIC BUSINESS (For HQ DLA, Executive/Staff Director or Higher; for PLFAs, Directorate Head or Higher)

A. ADMINISTRATIVE ERROR: Administrative or clerical error causing the forfeiture of annual leave. Evidence or supporting documents must be

attached. Briefly describe the error and the surrounding circumstances in the space provided on front of this form.

B. SICKNESS: Illness, injury, or medical condition requiring the use of sick leave, which precluded the use of scheduled annual leave. Such sickness

must have occurred at such a time late in the leave year, or, was of such duration, that the annual leave could not be rescheduled for use before the

end of the leave year. Attach OPM 71 and/or other supporting documents. State periods employee was on sick leave in Items 4 and 5. If ending date is

later than end of leave year and is unknown, an estimate must be given.

C. EXIGENCY OF THE PUBLIC BUSINESS: Management decision that specific kinds of operational demands or requirements are of such

magnitude or significance that employees cannot be excused from duty to avoid forfeiture of scheduled annual leave.

 1. Operational demands precluding the use of scheduled annual leave must be described fully.

 2. Explain how the above operational demands were of such magnitude that there were no reasonable alternatives to cancelling scheduled annual

leave. Describe fully. 

a. NAME b. DATE c. SIGNATURE

SECTION IV - APPROVAL/DISAPPROVALOF REQUEST (To be completed by Servicing Customer Support Office (CSO))

TO INFORMATION COPY TO:

20. REQUEST IS APPROVED FOR HOURS.

21. REQUEST IS DISAPPROVED.

22. REMARKS

23. CUSTOMER ACCOUNT MANAGER SIGNATURE 24. DATE 25. APPROVED RESTORATION PERIOD FOR THIS

REQUEST EXPIRES (DATE)

DLA FORM 1868, MAY 2003 (BACK) (EG)

REFERENCES

A. DLA One Book, LEAVE.

B. DLA Agreement with AFGE Council 169.

INTRODUCTION

 Supervisors are responsible for (1) establishing leave schedules early in the year to ensure that all employees are given an opportunity for a reasonable vacation, and,

(2) scheduling or rescheduling leave throughout the year so that employees use any leave that would otherwise be forfeited at the end of the leave year. Supervisors are

further reminded to review subordinates' annual leave situation at least semiannually. Failure to carry out the above responsibilities may result in the return of this request

without action. 

DEFINITIONS

FROM