Instructions for Applying to Become an Approved Leave Recipient

(FSIS Directive 4630.2. Revision 2. Voluntary Leave Transfer Program)

To qualify for the Leave Transfer Program (LTP): 

1. You must be absent from duty for a prolonged period due to a personal or family medical emergency.

2. You must have already been absent or expect to be absent from duty without pay for at least 24 hours or be

on advanced leave for at least 24 hours (or a prorated amount for part-time employees) during the period of

absence(s). If you have a personal or family medical emergency, you must have already used or expect to

exhaust your accrued annual leave and sick leave. (See Directive 4630.2.)

3. Your absence from work must have been approved by your supervisor (i.e., you must have applied and

been approved for an approved leave status such as, paid leave, advanced leave or leave without pay).

Applying to become an Approved Recipient under Leave Transfer Program: 

1. Complete Part I of the Form AD-1046, Leave Transfer Program-Recipient Application. Note: Completion of

Part I, number 18, is voluntary. If you choose to provide this information, it will be listed with other LTP

recipients on the LTP sharepoint site. Publication of recipient names is intended solely to assist recipients in

getting leave donations. This information is not used for any other purpose.

2. Attach to the Form AD-1046, a brief statement describing your medical emergency, including the nature and

severity of the emergency, and the expected duration. On this attachment, also explain your current leave

status (e.g., “I am in leave without pay status beginning August 1, not to exceed one year.”) and let us know if

you have applied for disability retirement or workers’ compensation benefits relating to this medical condition.

3. Attach a copy of the medical certificate or doctor’s statement on letterhead and signed by the physician

which describes the personal or family medical condition, the length of time you will likely be affected by the

condition, and the anticipated return to work date. 

4. Submit the completed application to your immediate supervisor for his/her concurrence or non-concurrence.

5. Send the completed application and attachment through your supervisor or district office to

PayAndLeaveGuidance@usda.gov; or mail to:

USDA, FSIS, OM, HRBSD 

Human Capital Planning and Accountability Branch 

1400 Independence Ave. SW 

Room 3144 - South Bldg. 

Washington, DC 20250-3700 

Fax: 202-720-5124
LEAVE TRANSFER PROGRAM - RECIPIENT APPLICATION

FOR PERSONNEL USE ONLY:

CASE NUMBER

INSTRUCTIONS: Use this form to apply to be a leave recipient under Public Law 100-566. Attach to this form a brief description of the nature and severity

of the medical emergency and 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. Approval as a leave recipient does not guarantee that leave will be donated. Donor employees will designate the recipient of their leave.

PART I - APPLICATION AND CERTIFICATION (To be completed by the applicant or another employee on his or her behalf)

1. NAME (Last, First, Middle Initial) 2. POSITION TITLE 3. SOCIAL SECURITY NUMBER

8. OFFICE TELEPHONE NO. 9. HOME TELEPHONE NO.

12. OFFICE ADDRESS OF TIMEKEEPER

4. SERIES, GRADE OR PAY LEVEL 5. DUTY STATION

10. NAME OF TIMEKEEPER 11. TELEPHONE NO. OF TIMEKEEPER

7. OFFICE ADDRESS

6. ORGANIZATIONAL TITLE (Agency, Division, Branch, Section)

15. DATES LEAVE EXHAUSTED

16. AMOUNT OF DONATED LEAVE

REQUESTED (hours, days or months) 14. ANTICIPATED OR ACTUAL DURATION

 OF MEDICAL EMERGENCY (if known)

Beginning Date: Ending Date:

13. T&A CONTACT POINT NO.

17. PLEASE INDICATE HOW YOU PREFER THE ANNUAL LEAVE DONATED TO BE APPLIED BY NUMBERING THE

FOLLOWING IN ORDER OF YOUR PREFERENCE. (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.)

For current use

against advanced

annual leave

against advanced

sick leave against LWOP

PLEASE INDICATE PAY PERIODS

DONATED ANNUAL LEAVE MAY

BE RETROACTIVELY APPLIED

18. I agree to have my (please specify):

case number only

case number, and

circumstances only

name, case number

and circumstances

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 possibly be made available to employees of my agency who wish to make donations to me.

CERTIFICATION (If certifying on behalf of another employee, modify as appropriate.)

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) I expect to be absent from duty

without paid leave at least 24 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.

SIGNATURE OF RECIPIENT OR HIS OR HER DESIGNEE (please specify):

TITLE

Recipient

Designee

CONCURRENCE: SIGNATURE OF SUPERVISOR

Yes

No

DATE

OFFICE TELEPHONE NO. DATE

6. ANNUAL LEAVE CATEGORY PER

PAY PERIOD

5. ADVANCED ANNUAL

LEAVE HOURS TO DATE

4. ADVANCED SICK

LEAVE HOURS TO DATE

3. LWOP HOURS USED IN

CONJUNCTION WITH THIS

EMERGENCY

PART II- AGENCY REVIEW AND APPROVAL

1. CURRENT ANNUAL

LEAVE BALANCE

(in hours)

2. CURRENT SICK

LEAVE BALANCE

(in hours)

APPLICATION APPROVED:

Yes

No

SIGNATURE OF APPROVING OR DISAPPROVING

OFFICIAL

TITLE OFFICE TELEPHONE NO. DATE

PRIVACY ACT STATEMENT

5 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.

AD-1046

Previous edition unusable (Rev. 4/89)

(state reason

for disapproval):

(If Yes, transferred leave may be credited to the recipient's account effective Pay Period Number):

Annual: Sick (if applicable):