Request to Donate Annual Leave to Leave Recipient

Under the Voluntary Leave Transfer Program

Privacy Act Statement

Participation in this program is voluntary; however; solicitation of this information is authorized under 5 U.S.C 6332. The information

furnished will be used to identify records properly associated with the transfer of annual leave. It may also be disclosed to a national, State,

or local law enforcement agency where there is an indication of a violation or potential violation of civil or criminal law, rule, or regulation; or

to another agency or court when the Government is party to a suit. Public Law 104-134 (April 26,1996) requires that any person doing

business with the Federal Government furnish a social security number or tax identification number. This is an amendment to title 31,

Section 7701. Furnishing the social security number, as well as other data, is voluntary, but failure to do so may delay or prevent action on

the application. If your agency uses the information furnished on this form for purposes other than those indicated above, it may provide you

with an additional statement reflecting those purposes.

I request that annual leave be transferred to the leave account of an approved leave recipient. This recipient is not my immediate

supervisor. As of the date indicated below, I have enough annual leave in my account to cover this amount. I understand that if I am

projected to forfeit annual leave during this leave year, the amount of leave I am transferring may not exceed the number of hours

remaining in the leave year for which I am scheduled to work. The amount of annual leave I am transferring also is not more than half the

hours I will earn this year.

I understand that my decision to transfer leave is not revocable. If a sufficient balance of unused donated leave remains after the

recipient's medical emergency has terminated, I can elect to have a pro-rated share returned to me during either the current leave year

or the following leave year, or I can elect to donate my pro-rated share to another leave recipient. However, to do so, I must remain

employed by a Federal agency and be subject to chapter 63 of title 5, United States Code. I have not been directly or indirectly

intimidated, threatened or coerced, or promised any benefit by any employee for the purpose of donating or using leave.

Part A - To Be Completed By Leave Donor

1. Name (Last, first, middle) 2. Social Security Number 3. Employee Number

4a. Position title

6. Leave donor's agency (Agency, Department, Office, Division, Branch, etc.)

7. Amount of annual leave accrued as of

end of last pay period

8. Amount of leave projected to forfeit this 

leave year as of end of last pay period

9. Amount of annual leave to be transferred

10. Leave recipient's name, agency, agency's address, organization (Agency, Department, Office, Division, Branch, etc.)

11a. Leave donor's signature 11b. Date signed

Office of Personnel Management

5 CFR 630

OPM 630-B

 June 2001 

Formerly Optional Form (OF) 630-B 

Local Reproduction Authorized

Outside

Agency

5. Relationship of leave donor to leave recipient (if any)

Part B - To Be Completed By Employing Agency of Leave Donor

Upon completion and approval of this form, forward a copy to the leave recipient's employing agency as soon as possible so that the

transfer of leave can take place.

12. Enter the amount of annual leave to be

credited to the leave recipient's annual

leave account

13. If the agency is waiving the maximum limitations for leave donation under the voluntary 

leave transfer program, describe the special circumstance that warrants the waiver

14a. Name of agency contact who can provide further information 14b. Telephone number

15. Certification: I certify that the leave donor currently has sufficient annual leave in his/her annual leave account to make a donation of the

requested amount of annual leave and that the amount of the donation does not exceed the maximum limitations for leave donation under

the voluntary leave transfer program.

15a. Signature of authorizing official 15b. Date Signed

4b. Pay plan 4c. Grade/pay level