Sf1150 Record Of Leave Data
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RECORD OF LEAVE DATA 1. Name (Last, First, Middle)
2. Social Security Number
3. (For agency use)
4. Date and Nature of Separation
5. A. Subject to 5 U.S.C. 6304(B) (45 day leave ceiling)
Yes
No
B. Last Date Subject to 5 U.S.C. 6304(B) C. Annual Leave Balance as of That Date (Hours) 6. Total Service for Leave (as of Date of Separation)
More than 15 Years Less Than 15 Years (show)
Years
Months
SUMMARY OF ANNUAL AND SICK LEAVE 7. Carryover Balance From Prior Leave Year Ending
MO.
DAY
YEAR
SUMMARY OF HOME LEAVE
HOURS Annual
Sick
Restored
8. Current Leave Year Accrual Through Pay Period Ending (if 90 day restriction applicable, explain in remarks) 9. Total
0.00
0.00
0.00
11. Total Leave Taken, Current Year Through Date of Separation
MO.
DAY
YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Date Started Date Completed
Hours Absent Without Pay Since That Date 20. Current Balance (or accrual) as of
12. Balance
Number of Days
13. Total Hours Paid in Lump Sum hours for holidays)
21. Twelve Months Accrual Date as of Date of Separation Number of Days
14. Salary Rate(s) Per Hour: 15.
MO.
Lump Sum Leave Dates (if part-time tour, explain in Remarks)
18. Basic Service Period of 24 Months of Continuous Service Abroad:
19. Current 12 Months Accrual Period Began on
10. Reduction in Credits, If Any (current year)
(includes
Days
DAY
YEAR
HOURS
From Thru
a. Restored
From
b. Annual Leave Above Ceiling
From
c. Annual Leave Within Ceiling
From
22. Dates Leave Used Prior 24 Months
FROM MO.
DAY
TO YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Thru Thru Thru
ABSENCE WITHOUT PAY 16. During Leave Year in Which Separated 17. A. Date of Last Equivalent Increase
Hours MO.
DAY
YEAR
B. Total AWOP Hours Since Last Equivalent Increase (except during military service and while in receipt of OWCP payments)
Hours
24. Remarks (include shore leave information, if applicable):
Last deduction for:
FEHB Code
Amt
Stand. FEGLI
Amt
Option A FEGLI
Amt
Option B FEGLI
Amt
Option C FEGLI
Amt
MILITARY LEAVE 23. During Current Calendar Year A. Regular Active Duty or Training B. Special Civil Disturbance
FROM MO.
DAY
TO YEAR
Balance of Unused Days for Current Fiscal Year (Block 23A)
Deducted Through
25. Certified Correct By: (Signature)
1150-113-01
DoD Exception to SF 1150 Approved by GSA/OIRM 9-85 DoD Exception - Use ONLY within DoD
26. Title, Agency, Address, Telephone Number
Reset
27. Date
STANDARD FORM 1150 (REV. 12-77) CIVIL SERVICE COMMISSION FPM SUPP. 296-31 AND 990-2 FormFlow V2.1
RECORD OF LEAVE DATA 1. Name (Last, First, Middle)
2. Social Security Number
3. (For agency use)
4. Date and Nature of Separation
5. A. Subject to 5 U.S.C. 6304(B) (45 day leave ceiling)
Yes
No
B. Last Date Subject to 5 U.S.C. 6304(B) C. Annual Leave Balance as of That Date (Hours) 6. Total Service for Leave (as of Date of Separation)
More than 15 Years Less Than 15 Years (show)
Years
Months
SUMMARY OF ANNUAL AND SICK LEAVE 7. Carryover Balance From Prior Leave Year Ending
MO.
DAY
YEAR
SUMMARY OF HOME LEAVE
HOURS Annual
Sick
Restored
8. Current Leave Year Accrual Through Pay Period Ending (if 90 day restriction applicable, explain in remarks)
0.00
0.00
10. Reduction in Credits, If Any (current year) 11. Total Leave Taken, Current Year Through Date of Separation
DAY
YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Date Completed
Hours Absent Without Pay Since That Date
Number of Days
13. Total Hours Paid in Lump Sum hours for holidays)
21. Twelve Months Accrual Date as of Date of Separation Number of Days
14. Salary Rate(s) Per Hour: 15.
MO.
Lump Sum Leave Dates (if part-time tour, explain in Remarks)
MO. Date Started
20. Current Balance (or accrual) as of
12. Balance (includes
18. Basic Service Period of 24 Months of Continuous Service Abroad:
19. Current 12 Months Accrual Period Began on
0.00
9. Total
Days
DAY
YEAR
HOURS
From Thru
a. Restored
From
b. Annual Leave Above Ceiling
From
c. Annual Leave Within Ceiling
From
22. Dates Leave Used Prior 24 Months
FROM MO.
DAY
TO YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Thru Thru Thru
ABSENCE WITHOUT PAY 16. During Leave Year in Which Separated 17. A. Date of Last Equivalent Increase
Hours MO.
DAY
YEAR
B. Total AWOP Hours Since Last Equivalent Increase (except during military service and while in receipt of OWCP payments)
Hours
24. Remarks (include shore leave information, if applicable):
Last deduction for:
FEHB Code
Amt
Stand. FEGLI
Amt
Option A FEGLI
Amt
Option B FEGLI
Amt
Option C FEGLI
Amt
MILITARY LEAVE 23. During Current Calendar Year A. Regular Active Duty or Training B. Special Civil Disturbance
FROM MO.
DAY
TO YEAR
Balance of Unused Days for Current Fiscal Year (Block 23A)
Deducted Through
25. Certified Correct By: (Signature)
1150-113-01
DoD Exception to SF 1150 Approved by GSA/OIRM 9-85 DoD Exception - Use ONLY within DoD
26. Title, Agency, Address, Telephone Number
Reset
27. Date
STANDARD FORM 1150 (REV. 12-77) CIVIL SERVICE COMMISSION FPM SUPP. 296-31 AND 990-2 FormFlow V2.1
2. Social Security Number
3. (For agency use)
4. Date and Nature of Separation
5. A. Subject to 5 U.S.C. 6304(B) (45 day leave ceiling)
Yes
No
B. Last Date Subject to 5 U.S.C. 6304(B) C. Annual Leave Balance as of That Date (Hours) 6. Total Service for Leave (as of Date of Separation)
More than 15 Years Less Than 15 Years (show)
Years
Months
SUMMARY OF ANNUAL AND SICK LEAVE 7. Carryover Balance From Prior Leave Year Ending
MO.
DAY
YEAR
SUMMARY OF HOME LEAVE
HOURS Annual
Sick
Restored
8. Current Leave Year Accrual Through Pay Period Ending (if 90 day restriction applicable, explain in remarks) 9. Total
0.00
0.00
0.00
11. Total Leave Taken, Current Year Through Date of Separation
MO.
DAY
YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Date Started Date Completed
Hours Absent Without Pay Since That Date 20. Current Balance (or accrual) as of
12. Balance
Number of Days
13. Total Hours Paid in Lump Sum hours for holidays)
21. Twelve Months Accrual Date as of Date of Separation Number of Days
14. Salary Rate(s) Per Hour: 15.
MO.
Lump Sum Leave Dates (if part-time tour, explain in Remarks)
18. Basic Service Period of 24 Months of Continuous Service Abroad:
19. Current 12 Months Accrual Period Began on
10. Reduction in Credits, If Any (current year)
(includes
Days
DAY
YEAR
HOURS
From Thru
a. Restored
From
b. Annual Leave Above Ceiling
From
c. Annual Leave Within Ceiling
From
22. Dates Leave Used Prior 24 Months
FROM MO.
DAY
TO YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Thru Thru Thru
ABSENCE WITHOUT PAY 16. During Leave Year in Which Separated 17. A. Date of Last Equivalent Increase
Hours MO.
DAY
YEAR
B. Total AWOP Hours Since Last Equivalent Increase (except during military service and while in receipt of OWCP payments)
Hours
24. Remarks (include shore leave information, if applicable):
Last deduction for:
FEHB Code
Amt
Stand. FEGLI
Amt
Option A FEGLI
Amt
Option B FEGLI
Amt
Option C FEGLI
Amt
MILITARY LEAVE 23. During Current Calendar Year A. Regular Active Duty or Training B. Special Civil Disturbance
FROM MO.
DAY
TO YEAR
Balance of Unused Days for Current Fiscal Year (Block 23A)
Deducted Through
25. Certified Correct By: (Signature)
1150-113-01
DoD Exception to SF 1150 Approved by GSA/OIRM 9-85 DoD Exception - Use ONLY within DoD
26. Title, Agency, Address, Telephone Number
Reset
27. Date
STANDARD FORM 1150 (REV. 12-77) CIVIL SERVICE COMMISSION FPM SUPP. 296-31 AND 990-2 FormFlow V2.1
RECORD OF LEAVE DATA 1. Name (Last, First, Middle)
2. Social Security Number
3. (For agency use)
4. Date and Nature of Separation
5. A. Subject to 5 U.S.C. 6304(B) (45 day leave ceiling)
Yes
No
B. Last Date Subject to 5 U.S.C. 6304(B) C. Annual Leave Balance as of That Date (Hours) 6. Total Service for Leave (as of Date of Separation)
More than 15 Years Less Than 15 Years (show)
Years
Months
SUMMARY OF ANNUAL AND SICK LEAVE 7. Carryover Balance From Prior Leave Year Ending
MO.
DAY
YEAR
SUMMARY OF HOME LEAVE
HOURS Annual
Sick
Restored
8. Current Leave Year Accrual Through Pay Period Ending (if 90 day restriction applicable, explain in remarks)
0.00
0.00
10. Reduction in Credits, If Any (current year) 11. Total Leave Taken, Current Year Through Date of Separation
DAY
YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Date Completed
Hours Absent Without Pay Since That Date
Number of Days
13. Total Hours Paid in Lump Sum hours for holidays)
21. Twelve Months Accrual Date as of Date of Separation Number of Days
14. Salary Rate(s) Per Hour: 15.
MO.
Lump Sum Leave Dates (if part-time tour, explain in Remarks)
MO. Date Started
20. Current Balance (or accrual) as of
12. Balance (includes
18. Basic Service Period of 24 Months of Continuous Service Abroad:
19. Current 12 Months Accrual Period Began on
0.00
9. Total
Days
DAY
YEAR
HOURS
From Thru
a. Restored
From
b. Annual Leave Above Ceiling
From
c. Annual Leave Within Ceiling
From
22. Dates Leave Used Prior 24 Months
FROM MO.
DAY
TO YEAR
MO.
DAY
YEAR
MO.
DAY
YEAR
Thru Thru Thru
ABSENCE WITHOUT PAY 16. During Leave Year in Which Separated 17. A. Date of Last Equivalent Increase
Hours MO.
DAY
YEAR
B. Total AWOP Hours Since Last Equivalent Increase (except during military service and while in receipt of OWCP payments)
Hours
24. Remarks (include shore leave information, if applicable):
Last deduction for:
FEHB Code
Amt
Stand. FEGLI
Amt
Option A FEGLI
Amt
Option B FEGLI
Amt
Option C FEGLI
Amt
MILITARY LEAVE 23. During Current Calendar Year A. Regular Active Duty or Training B. Special Civil Disturbance
FROM MO.
DAY
TO YEAR
Balance of Unused Days for Current Fiscal Year (Block 23A)
Deducted Through
25. Certified Correct By: (Signature)
1150-113-01
DoD Exception to SF 1150 Approved by GSA/OIRM 9-85 DoD Exception - Use ONLY within DoD
26. Title, Agency, Address, Telephone Number
Reset
27. Date
STANDARD FORM 1150 (REV. 12-77) CIVIL SERVICE COMMISSION FPM SUPP. 296-31 AND 990-2 FormFlow V2.1
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