Fillable Printable VA Form 0862
Fillable Printable VA Form 0862
VA Form 0862
OMB Number: 2900-0669
Respondent Burden: 15 minutes
CLAIM FOR CREDIT OF ANNUAL LEAVE
NOTE: Please review page 2 for Privacy Act Statement and Respondent Burden before completing this form.
INSTRUCTIONS: The Federal Circuit in Butterbaugh v. Dept. of Justice, 336 F.3d 1332 (Fed. Cir. 2003), held that military leave should not have been charged prior to
December 21, 2000 (the date of the change in the military leave law) for administrative non-duty days that fell within a period of military leave. The Office of Personnel
Management (OPM) issued guidance for processing Butterbaugh-type administrative claims for annual leave which provided that, under the Barring Act, a leave claim
must be brought within six years after the claim accrued. However, the Merit System Protection Board (MSPB) has ruled that a Butterbaugh-related claim is a claim
under the Veterans Reemployment Rights Act (VRRA). Although the leave provisions of Chapter 63 of Title 5, United States Code (U.S.C.), specifically pertain to Title
5 employees, VA is extending the provisions of Butterbaugh to employees covered by regulations prescribed by VA pursuant to Title 38, U.S.C. 7421(a). Accordingly,
for Title 5 and Title 38 employees who are charged leave on an hourly basis, VA may accept administrative claims filed after July 24, 2003, for crediting additional leave
for military leave charged on administrative nonduty days between October 1, 1980, and December 21, 2000. Administrative claims filed after July 24, 2003, by Title 38
employees on 24/7 schedules for crediting annual leave for military leave charged on administrative nonduty days may be accepted back to October 1, 1980.
It is your responsibility to establish the validity of your claim by providing supporting documentation such as a copy of your military orders, certification of attendance,
or other documents indicating that you engaged in periods of active military duty for which you were charged military leave on nonworkdays. Failure to submit
supporting documentation may result in the denial of your claim.
Submit your signed and dated claim, VA Form 0862, and supporting documentation to your local payroll office. If you are a retired annuitant or separated from the
service of the VA, submit your claim to your last servicing payroll office.
NAME OF APPLICANT SOCIAL SECURITY NO.
DAYTIME PHONE NUMBER (Include area code)
HOME MAILING ADDRESS (street, city, state, ZIP code)
CHECK APPLICABLE BOX
CURRENT EMPLOYEE
DATE
RETIRED ANNUITANT
SEPARATED/RESIGNATION FROM FEDERAL SERVICE
INSTRUCTIONS: Indicate below the period of time for which you are submitting a claim for leave
TITLE 5 EMPLOYEES
1980
DATES (Attach documentation)
FROM TO
1981
DATES (Attach documentation)
FROM TO
1982
DATES (Attach documentation)
FROM TO
1983
DATES (Attach documentation)
FROM TO
1984
DATES (Attach documentation)
FROM TO
1985
DATES (Attach documentation)
FROM TO
1986
DATES (Attach documentation)
FROM TO
1987
DATES (Attach documentation)
FROM TO
1988
DATES (Attach documentation)
FROM TO
1989
DATES (Attach documentation)
FROM TO
1990
DATES (Attach documentation)
FROM TO
1991
DATES (Attach documentation)
FROM TO
1992
DATES (Attach documentation)
FROM TO
1993
DATES (Attach documentation)
FROM TO
1994
DATES (Attach documentation)
FROM TO
1995
DATES (Attach documentation)
FROM TO
1996
DATES (Attach documentation)
FROM TO
1997
DATES (Attach documentation)
FROM TO
1998
DATES (Attach documentation)
FROM TO
1999
DATES (Attach documentation)
FROM TO
2000
DATES (Attach documentation)
FROM TO
RESERVED
VA FORM
JAN 2008
0862
TITLE 38 EMPLOYEES
1980
DATES (Attach documentation)
FROM TO
1981
DATES (Attach documentation)
FROM TO
1982
DATES (Attach documentation)
FROM TO
1983
DATES (Attach documentation)
FROM TO
1984
DATES (Attach documentation)
FROM TO
1985
DATES (Attach documentation)
FROM TO
1986
DATES (Attach documentation)
FROM TO
1987
DATES (Attach documentation)
FROM TO
1988
DATES (Attach documentation)
FROM TO
1989
DATES (Attach documentation)
FROM TO
1990
DATES (Attach documentation)
FROM TO
1991
DATES (Attach documentation)
FROM TO
1992
DATES (Attach documentation)
FROM TO
1993
DATES (Attach documentation)
FROM TO
1994
DATES (Attach documentation)
FROM TO
1995
DATES (Attach documentation)
FROM TO
1996
DATES (Attach documentation)
FROM TO
1997
DATES (Attach documentation)
FROM TO
1998
DATES (Attach documentation)
FROM TO
1999
DATES (Attach documentation)
FROM TO
2000
DATES (Attach documentation)
FROM TO
2001
DATES (Attach documentation)
FROM TO
2002
DATES (Attach documentation)
FROM TO
2003
DATES (Attach documentation)
FROM TO
2004
DATES (Attach documentation)
FROM TO
2005
DATES (Attach documentation)
FROM TO
RESERVED
Does the above period of time include dates during which you were employed by an agency other than the
Department of Veterans Affairs?
YES NO
(If "YES," have you submitted a claim for leave to that agency?"
YES NO
LEAVE CHARGED ON
AN HOURLY BASIS A DAILY BASIS (not less than 8 hours)
SIGNATURE OF APPLICANT DATE (MM/DD/YYYY)
PRIVACY ACT STATEMENT: Furnishing your social security number, as well as all other data, is voluntary. Providing your social security number will enable the
Payroll Office to accurately process your claim for restored annual leave or lump-sum payment, whichever is applicable. Executive Order 9397 authorizes use of your
social security number for the orderly administration of personnel records. Disclosure of this information may be made in accordance with the disclosure provisions of
the Privacy Act of 1974. Employee payroll records are contained in VA System of Records (SOR) 27VA047, Personnel and Accounting Pay Systems. Routine use
disclosures include providing payroll information to other Federal agencies such as the Office of Personnel Management, Social Security Administration, and Department
of Treasury for retirement, social security crediting, and tax administration. Also, disclosure may be made within the Department to assist in the collection of unpaid
financial obligations owed to VA.
RESPONDENT BURDEN: The Department of Veterans Affairs (VA) may not conduct or sponsor, and the respondent is not required to respond to this collection of
information unless it displays a valid OMB Control Number. The information is necessary to accomplish your claim for annual leave credit as a result of the decision in
the Butterbaugh v. Department of Justice, 336 F.3d 1332 (Federal Circular 2003).
Public reporting burden for this collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing the form. Send comments regarding this burden estimate or any other aspects of this collection, including
suggestions for reducing this burden, to VA Clearance Officer (005E3), 810 Vermont Avenue, Washington, DC 20420. SEND COMMENTS ONLY. DO NOT SEND
THIS FORM OR REQUEST FOR BENEFITS TO THIS ADDRESS.
VA FORM 0862, JAN 2008, PAGE 2
