Fillable Printable Record Of Leave Data
Fillable Printable Record Of Leave Data
Record Of Leave Data
SUMMARY OF ANNUAL AND SICK LEAVE
8. Current Leave
Year Accrual Through Pay Period Ending
(if 90 day restriction applicable,
explain in remarks)
RECORD OF LEAVE DATA
1. Name (Last, First, Middle) 2. Social Security Number
3. (For agency use)
4. Date and Nature of Separation 5. A. Subject to 5 U.S.C. 6304(B) (45 day leave ceiling)
Yes No
B. Last Date Subject to 5 U.S.C. 6304(B)
More than 15 Years
Less Than 15 Years (show)
Years
Months Days
SUMMARY OF HOME LEAVE
MO. DAY
YEAR
HOURS
Annual
Sick
Restored
9. Total
11. Total Leave Taken, Current Year Through
Date of Separation
12. Balance
13. Total Hours Paid in Lump Sum
(includes hours for holidays)
14. Salary Rate(s) Per Hour:
MO. DAY YEAR
HOURS
From
Thru
From
Thru
From
Thru
From
Thru
15.
Lump Sum Leave Dates (if part-time
tour, explain in Remarks)
a. Restored
b. Annual Leave Above Ceiling
c. Annual Leave Within Ceiling
ABSENCE WITHOUT PAY
16. During Leave Year in Which Separated
Hours
17. A. Date of Last Equivalent Increase
MO.
DAY
YEAR
Hours
18. Basic Service Period of 24
Months of Continuous
Service Abroad:
MO.
DAY
YEAR
Date Started
Date Completed
19. Current 12 Months Accrual Period
Began on
MO.
DAY YEAR
Hours Absent Without Pay Since
That Date
20. Current Balance (or accrual) as of
MO. DAY
YEAR
Number of Days
21. Twelve Months Accrual Date as of Date of Separation
Number of Days
22. Dates Leave
Used Prior 24
Months
MO. DAY
YEAR MO. DAY
YEAR
FROM
TO
MO.
DAY
YEAR MO.
DAY
YEAR
FROM
TO
MILITARY LEAVE
24. Remarks (include shore leave information, if applicable):
25. Certified Correct By: (Signature) 26. Title, Agency, Address, Telephone Number 27. Date
1150-113
STANDARD FORM 1150 (REV. 12-77)
CIVIL SERVICE COMMISSION
FPM SUPP. 296-31 AND 990-2
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7. Carryover Bal-
ance From
Prior Leave
Year Ending
6. Total Service for
Leave (as of Date
of Separation)
C. Annual Leave Balance as of That Date
(Hours)
B. Total LWOP Hours Since Last Equivalent increase (except
during military service and while in receipt of OWCP payments)
23. During Current
Calendar Year
A. Regular-
Active Duty
or Training
B. Special-
Civil
Disturbance
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10. Reduction in Credits, If Any (current year)
