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OPM Form 630

A potential leave recipient must complete Form OPM-630, Application to Become a Leave Recipient Under the Voluntary Leave Transfer Program, and:

  • Indicate the hours of leave requested to be donated. This may include an amount to liquidate an indebtedness for advanced annual or sick leave or retroactively substitute for periods of leave without pay which were directly related to the instant medical emergency;
  • Provide a brief description, not to exceed 100 words, of the nature and severity of the medical emergency; and
  • Attach documentation of the medical emergency stating the medical condition, the prognosis, anticipated duration of the condition, and if it is a recurring one, the approximate frequency of the medical emergency.

If the application is made on behalf of you as an incapacitated employee, the form must include a statement signed by you or a member of your immediate family or other appropriate person (such as an individual with power of attorney), expressly authorizing the personal representative to make such application. The statement must indicate the relationship of the signer to you as the recipient.

If you are caring for another person, the form must include a certificate from one or more health care providers specifying the:

  • Medical condition of that person
  • Prognosis
  • Anticipated duration of the condition, and if it is a recurring one
  • Approximate frequency of the medical emergency

For an application to be considered for approval, you or your personal representative must submit the application within 30 calendar days of the termination of a medical emergency.