INSTRUCTIONS: Use this form to apply to be a leave recipient under P.L. 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 OF RECIPIENT (Last, First, Middle Initial)
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.)
PLEASE INDICATE PAY PERIOD DONATED ANNUAL LEAVE MAY BE RETROACTIVELY APPLIED
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 be published exactly as I write made available to employees of my agency who which 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) expect to be absent from duty without paid leave at least 80 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):
§ 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.