FOR PERSONNEL USE ONLY:

LEAVE TRANSFER PROGRAM - DONOR APPLICATION CASE NUMBER

INSTRUCTIONS: Use this form to request the transfer of earned annual leave to an approved leave recipient under P.L.1OO-566. You may not transfer leave to your

immediate supervisor. After completion, forward it to the office In your agency designated to approve leave donatlons.

PART I - COMPLETED BY DONOR

1. NAME OF DONOR (Last,First, MiddleInitial) 2. POSlTlON TlTLE

3. SOCIAL SECURlTY NUMBER 4. SERIES, GRADE OR PAY LEVEL 5. ORGANIZATIONAL TITLE (Agency, Division, Branch, Section) 

6. OFFICE ADDRESS 7. OFFICE TELEPHONE NO.

8. NAME OF TIMEKEEPER 9. TELEPHONE NO. OF TlMEKEEPER 10. OFFICE ADDRESS OF TIMEKEEPER 

INSTRUCTlONS: Please review the information below. You may not transfer more than 1/2 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.

lf you will be employeed full-thne by the federal government for the full calendar year, the limits are as follows:

52 hours for employees In the 4-hour leave earning category.

76 hours for employees In the 6-hour leave earning category, or

104 hours for employees in the 8-hour leave earning category.

Limit for part-time employee = 13 X Duty hours In Pay Period X

X

80

Llmlt for part-year employee = Number of Pay Periods to be worked

2

11. NUMBER OF HOURS OF ANNUAL

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12. NAME OF RECIPIENT

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13. CASE NUMBER

LEAVE TO BE TRANSFERRED

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14. SOCIAL SECURITY NUMBER OF

RECIPIENT (lf known)

15. ORGANlZATlONAL LOCATION OF RECIPIENT (Agency, Division, Branch, Section) 

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16. OFFICE ADDRESS OF RECIPIENT

17. NAME OF LEAVE SHARE COORDINATOR 18.TELEPHONE NO. OF LEAVE SHARE

 COORDINATOR

19. OFFICE ADDRESS OF LEAVE SHARE COORDINATOR

 CERTIFICATION OF VOLUNTARY DONATION: 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

PART Il. AGENCY REVIEW AND APPROVAL

1. CURRENT ANNUAL LEAVE AS OF PAY PERIOD NUMBER

(in hours)

2. ANNUAL LEAVE CATEGORY PER PAY PERIOD

APPLICATION APPROVED:

Yes (This application meets all criteria required for annual leave transfer by law, regulation and Department policy.

Transferred leave may be credited to the recipient’s account effective Pay Period Number):

SIGNATURE OF APPROVING OR DISAPPROVING

OFFICIAL 

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OFFICE TELEPHONE NO. DATE

PRIVACY ACT STATEMENT

5 U.S.C. 6311 authorizes collection of this Information. Your socialsecurity 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.

Previous edition unusable (Rev. 4/89)

lf you are a part-time employee or If you wlll not be employed for the full calendar year, you may compute your transfer limit using the appropriate formula 

below:

leave earning category

leave earning category

donate annual leave. I understand that except for any leave unused by the recipient, I have no right under any circumstances (Including a medical emergency of my 

own) to have any of the donated leave restored.

SIGNATURE OF DONOR DATE

No (state reason for disapproval):

TITLE

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