Fill and Sign the Ao 193 Request for Personnel Action Form

OAO 193 (Rev. 4/05) REQUEST FOR PERSONNEL ACTION PART A 1. Requesting Office: 1a. Court Code: 2. Type of Action Requested and NOA Code : 3.NTE (if applicable) 4. Tour of Duty: 2a. Effective Date: 5. Employee Name: ( Last, First, Middle Initial ) 6a. HRMIS Employee ID: 6b. Social Security Number: FROM TO 7. Position Title: 8. Position Title: Occupational Series:* Occupational Series:* Job Category:* Job Category:* Grade/Step: Grade/Step: Position Number: Position Number: Special Pay Rate: Y: ’ N: ’ Sch: Special Pay Rate: Y: ’ N: ’ Sch: 9. Name and Mailing Address of Current Org. ( Duty Station) 10. Name and Mailing Address of New Org. ( Duty Station) 11. Remarks: * Occupational series and job categories are required for all CPS positions, except Law Enforcement Officer (LEO) position s. See attached check lists for appointments/separations. 12. For Additional Information Call: Name: Telephone Number: 13. Appointing Officer Name: Title: Signature: Date: This request is submitted with the approval of the court (if required) PART B — AO USE ONLY 1. Requesting Office: Action: Grade Step:Occ Series/Job Position Number: Effective Date: Staffed By: Date Staffed: PART C: APPOINTMENT CHECK LISTEmployee Name: Social Security No.: If transferring without a break in service of more than three (3) calendar days from another federal ( or District of Columbia) government agency, give: Name of Agency: Date of Separation: Address of Agency: Telephone Number of Civilian Personnel Office : ( if known) NOTE: Must complete Form AO 425, Pre-Employment Information Note: For some appointments, such as temporary ones, not all forms will be required; for others, additional forms are required. Plea se check the Human Resources Manual , Sections 4 and 5, if in doubt as to which forms are necessary. ’ AO 75 , Law Clerk Appointment Checklist & Leave Act Certification (if applicable) OR ’ SF 1152 , Designation of Beneficiary Unpaid Compensation of Deceased Civilian Employee Program ’ AO 75A , Staff Attorney Appointment Checklist ’ SF 2808 , Designation of Beneficiary, CSRS ’ AO 78 , Application for Judicial Branch Federal Employment ’ SF 2809 , Health Benefits Registration form (if applicable) ’ AO 78A , United States Courts Appointment ’ SF 2817 , Life Insurance Election, Federal Employees’ Group Life Insurance (FEGLI) Program (if applicable) ’ AO 80 , Clerks’ and Deputy Clerks’ Oath (if applicable) ’ SF 2823 , Designation of Beneficiary, Federal Employees’ Group Life Insurance (FEGLI) Program ’ AO 425 , Pre-Employment Information ’ SF 3102 , Designation of Beneficiary, FERS ’ DD 214, Notice of Separation from Military Service, member 4 copy (if applicable) ’ State and/or City Tax Withholding Forms (if applicable) ’ SF 1199A ,Direct Deposit Sign-up Form OR ’ TSP-1 , Thrift Savings Plan Election Form ’ FMS 2231 , Direct Deposit Sign-up Form ’ I-9 , Employment Eligibility Verification (must complete within 3 days of Entry On Duty (EOD) date) ’ TSP-1-C , Thrift Savings Plan Catch-up Contribution Election ’ AO 194 or AO 195 Position Description (if applicable) ’ TSP-3 , Thrift Savings Plan Designation of Beneficiary (Do not mail to AO, mail directly to National Finance Center) including signed Position Classification Certification Form ’ SB-2362 , Authorization for Purchase (Savings Bond) ’ W 4 , Employee’s Withholding Allowance Certificate (Federal Tax Withholding) (Date) (Signature of Human Resources Representative) PART D: SEPARATION CHECK LIST (Check if applicable ) Employee Name: Social Security No.: 1. Forwarding Address: Tel. No. ( ) 2. ’ Employee’s statement of resignation attached. 3. ’ If no statement of resignation is attached, state reason(s) fo r separation and have employee sign below in Box 12. Note: Reasons listed are used in determining severance pay entitlement and possible unemployment benefits. Please be specific. 4. ’ Employee is transferring without a break in service to : ( Federal Agency name, address & phone) 5. ’ If applicable, attach statement from Appointing Officer concerning nature of separation. 6. ’ Employee received/mailed Notice of Change in Health Benefits Enrollment Form ( SF 2810 ) on . (date ) 7. ’ Employee received/mailed a Federal Employees Temporary Continuation of Coverage Health Benefits package on . ( date ) 8. ’ Employee received/mailed an Unemployment Compensation Form ( SF-8 ) on (date ) 9. ’ Employee received/mailed a Thrift Savings Plan Withdrawal Folder on (date ) 10. ’ Employee received/mailed an Application for Refund of Retirement Deductions SF 2802 or SF 3106 (date ) 11. ’ Employee has been informed that final salary and payment for lump sum annual leave will be made via direct deposit to account of record. Employee counseled regarding importance of keeping acc ounts open as long as he or she expects to receive payments. 12. Human resources representative’s signature: Date: 13. Employee’s signature: Date: PART E: SEPARATION CHECK LIST CONCERNING FINANCIAL OBLIGATIONS 1. ’ Employee is covered by the Leave Act ’ SF 1150 , Record of Leave Data attached (if covered) ’ Copy of original AO 75/75A attached (for law clerk/staff attorney) 2. ’ Employee has negative leave balances of hours annual leave/ hours sick leave. 3. ’ Employee has outstanding travel/salary advance(s) of 4. ’ Employee is leaving the federal government and has not completed his/her one year relocation agreement. Human Resources Representative’s signature: Date: 5. ’ “I hereby authorize the Administrative Office of the United Stat es Court to collect from my retirement fund any indebtedness ow ed to the federal government.” 6. ’ “I hereby surrender to the human resources representative my fede ral I.D. card, government credit cards and all keys issued to me or in my custody.” Employee’s signature: Date: