SF71 Thomas Mohr 4/6/98 4/6/98 application/x-xfdl application/x-xfdl 1.0.0 letter 120 8.0;10.5 PAGE1 235 235 235 Courier 9 plain REQUEST FOR LEAVE OR APPROVED ABSENCE Helvetica 14 bold center 61 1 absolute 19 3 extent 874 34 absolute 20 35 extent 79 26 1. NAME Times 10 bold absolute 100 35 extent 218 26 (Last, First, Middle Initial) Times 10 plain italic absolute 511 35 extent 385 26 2. EMPLOYEE OR SOCIAL SECURITY NUMBER Times 10 bold absolute 20 85 extent 170 26 3. ORGANIZATION Times 10 bold absolute 20 135 extent 248 26 4. TYPE OF LEAVE/ABSENCE Times 10 bold absolute 32 155 extent 236 26 (Check appropriate box(es) below.) Times 9 plain italic absolute 270 158 extent 48 22 From: Times 9 bold absolute 268 135 extent 163 26 Date Times 10 bold center absolute 352 158 extent 48 22 To: Times 9 bold absolute 432 158 extent 48 22 From: Times 9 bold absolute 430 135 extent 163 26 Time Times 10 bold center absolute 513 158 extent 48 22 To: Times 9 bold absolute 592 134 extent 80 46 Total Hours Times 10 bold center absolute 64 186 extent 205 26 Accrued Annual Leave Times 10 bold absolute 64 232 extent 205 26 Restored Annual Leave Times 10 bold absolute 64 278 extent 205 26 Advance Annual Leave Times 10 bold absolute 64 323 extent 205 26 Accured Sick Leave Times 10 bold absolute 64 368 extent 205 26 Advance Sick Leave Times 10 bold absolute 19 409 extent 80 26 Purpose: Times 10 bold absolute 142 410 Medical/dental/optical Examination of requesting employee Times 9 plain 45 1 absolute 535 410 extent 46 24 Other Times 9 plain absolute 142 435 extent 439 42 Care of family member/bereavement, including medical/dental/optical examination of family member Times 9 plain absolute 64 498 extent 204 26 Compensatory Time Off Times 10 bold absolute 64 535 extent 180 26 Other Paid Absence Times 10 bold absolute 64 556 extent 158 24 (Specify in Remarks) Times 9 plain italic absolute 64 593 extent 192 26 Leave Without Pay Times 10 bold absolute 676 135 extent 215 46 5. FAMILY AND MEDICAL LEAVE Times 10 bold absolute 677 183 extent 214 126 If annual leave, sick leave, or leave without pay will be used under the Family and Medical Leave Act of 1993, please provide the following information: Times 10 plain I hereby invoke my Times 10 bold absolute 700 322 extent 191 26 entitlement Family and Times 10 bold absolute 675 342 extent 216 26 Medical Leave for: Times 10 bold absolute 675 364 extent 215 26 absolute 708 403 extent 181 22 Birth/Adoption/Foster Care Times 8 plain absolute 708 426 extent 182 38 Serious Heath Condition of spouse, Son, Daughter, or Parent Times 8 plain absolute 708 483 extent 184 22 Serious Health Condition of Self Times 8 plain absolute 675 537 Contact your supervisor and/or our personnel office to obtain additional information about your entitlements and responsibilities under the Family and Medical Leave Act of 1993. Times 8 plain 26 5 absolute 19 630 extent 192 26 6. REMARKS: Times 10 bold absolute 19 747 extent 170 26 7. CERTIFICATION: Times 10 bold absolute 178 747 extent 715 26 I hereby request leave/approved absence from duty as indicated above and certify that such leave/absence Times 10 plain absolute 19 767 extent 873 66 is reuested from the purpose(s) indicated. I understand that I must comply with my employing agency's procedures for requesting leave/approved absence (and provide additional documention, including medical certification, if required) and that falsification of information on this form may be grounds for disciplinary action, including removal. Times 10 plain absolute 19 841 extent 230 27 EMPLOYEE SIGNATURE Times 11 bold absolute 597 841 extent 58 27 DATE Times 11 bold absolute 19 877 extent 335 26 8. OFFICAL ACTION ON REQUEST: Times 10 bold absolute 41 897 (If disapproved, give reason. If annual leave, initiate action to reschedule.) Times 10 plain 53 1 absolute 388 875 extent 192 26 APPROVED Times 10 bold absolute 638 875 extent 192 26 DISAPPROVED Times 10 bold absolute 19 941 extent 112 27 SIGNATURE Times 11 bold absolute 597 940 extent 58 27 DATE Times 11 bold absolute 17 970 extent 876 26 PRIVACY ACT STATEMENT Times 10 bold center absolute 19 996 extent 873 134 Section 6311 of title 5, United States Code, authorizes collection of this information. The primary use of this information is by management and your payroll office to approve and record your use of leave. Additional disclosures of the information mat be: To the Department of labor when processing a claim for compensation regarding a job connected injury or illness; to a State unemployment compensation office regarding a claim; the Federal Life Insurance or Health Benefits carries regarding a claim; to a Federal State, or local law enforcement agency when your agency becomes aware of a violation or possible violation of civil or criminal law; to a Federal agency when conducting an investigation for employment or Services Administration in connection with its responsibilities for records management. Where the Employee identification number is your Social Security Number, collection of this information is authorized by Executive Order 9397. Furnishing the information on this form, including your Social Security Number, is voluntary, but to do so may result in disapproval request. Times 8 plain 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. Times 7 plain absolute 18 1140 extent 875 22 absolute 18 1168 extent 422 38 NSN 7540-000-753-5067 PREVIOUS EDITION MAY BE USED Times 8 plain absolute 438 1168 extent 454 38 STANDARD FORM 71 (Rev. 12-97) PRESCRIBED BY OFFICE OF PERSONNEL MANAGEMENT, 5 CFR PART 630 Times 8 plain right absolute 17 32 extent 876 1 absolute 17 82 extent 876 1 absolute 17 133 extent 876 1 absolute 17 179 extent 876 1 absolute 268 218 extent 406 1 absolute 268 263 extent 406 1 absolute 17 311 extent 657 1 absolute 268 354 extent 406 1 absolute 268 398 extent 406 1 absolute 17 484 extent 657 1 absolute 17 530 extent 657 1 absolute 17 578 extent 657 1 absolute 17 626 extent 876 1 absolute 17 743 extent 876 1 absolute 17 867 extent 876 1 absolute 17 967 extent 876 1 absolute 17 1164 extent 876 1 absolute 17 32 extent 1 1133 absolute 510 32 extent 1 51 absolute 892 32 extent 1 1133 absolute 268 133 extent 1 266 absolute 349 179 extent 1 220 absolute 430 133 extent 1 266 absolute 510 179 extent 1 220 absolute 592 133 extent 1 265 absolute 673 133 extent 1 494 absolute 268 484 extent 1 143 absolute 349 484 extent 1 143 absolute 431 484 extent 1 143 absolute 510 484 extent 1 143 absolute 591 484 extent 1 143 absolute 20 58 extent 489 23 string mandatory wordwrap fixed 0 John Q. 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