Free VA Form VA0862 - Claim for Credit of Annual Leave - Federal

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 RETIRED ANNUITANT SEPARATED/RESIGNATION FROM FEDERAL SERVICE

DATE

INSTRUCTIONS: Indicate below the period of time for which you are submitting a claim for leave TITLE 5 EMPLOYEES
DATES (Attach documentation) DATES (Attach documentation) DATES (Attach documentation)

1980

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1981

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1982

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1983

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1986

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1988

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1989

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1991

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1992

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1994

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1995

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RESERVED

VA FORM JAN 2008

0862

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TITLE 38 EMPLOYEES
DATES (Attach documentation) DATES (Attach documentation) DATES (Attach documentation)

1980

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1981

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1982

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1983

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1984

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1985

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1986

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1987

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1988

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1989

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1990

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1991

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1992

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1993

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1994

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1995

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1996

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1997

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1998

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1999

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2000

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2001

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2002

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2003

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RESERVED

2004

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2005

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Does the above period of time include dates during which you were employed by an agency other than the (If "YES," have you submitted a claim for leave to that agency?" Department of Veterans Affairs? YES NO
LEAVE CHARGED ON AN HOURLY BASIS SIGNATURE OF APPLICANT A DAILY BASIS (not less than 8 hours)

YES

NO

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 insturctions, 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

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