Fillable Printable OPM Form 630A

OPM Form 630A

Request to Donate Annual Leave to Leave Recipient

Within

Under the Voluntary Leave Transfer Program

Agency

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 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.

To Be Completed By Leave Donor

1. Name

(Last, first, middle)

2. SSN (last 4 digits) 3. Employee Number

4a. Position title

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

5a. Name of organization (Agency, Department, Office, Division, Branch, etc.)

5b. Office telephone number

6. Amount of annual leave accrued as of 7. Amount of leave projected to forfeit this 8. Amount of annual leave to be transferred

end of last pay period leave year as of end of last pay period

9. Individual's name or identification number to whom leave is being donated

10a. Signature

10b. Date signed

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.

Office of Personnel Management

5 CFR 630

Local Reproduction Authorized

OPM 630-A

August 2013

Formerly Optional Form (OF) 630 A

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