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OF69 – Rev 2-89
Office of Personnel Management
FPM Chapter 334

ASSIGNMENT AGREEMENT
Title IV of the Intergovernmental Personnel Act of 1970 (5 U.S.C. 3371 – 3376)

INSTRUCTIONS

This agreement constitutes the written record of the obligations and responsibilities of the parties to a temporary assignment arranged under the provisions of the Intergovernmental Personnel Act of 1970. The term “State or local government,” when appearing on this form, also refers to an institution of higher education, an Indian tribal government, and any other eligible organization. Copies of the completed and signed agreement should be retained by each signatory. Within 15 days of the effective date of the assignment, two copies of this form must be sent to: U.S. Office of Personnel Management Personnel Mobility Program Staffing Operational Division/CEG 1900 E Street, NW Washington, DC 20415 Procedural questions on completing the assignment agreement form or on other aspects relating to the mobility program should be addressed to either mobility program coordinators in each Federal agency or to the staff of the Personnel Mobility Programs in the U.S. Office of Personnel Management.

 

PART 1 · NATURE OF THE ASSIGNMENT AGREEMENT

1. Check Appropriate Box
New Agreement
Modification
Extension

 

PART 2 · INFORMATION ON PARTICIPATING EMPLOYEE

2. Name (Last, First, Middle) 3. Social Security Number


4. Home Address (Street, City, State, ZIP Code) 5. · A. Have you ever been on a mobility assignment?
YES
NO
5. · B. If “YES”, date of each assignment (Month and Year)
From To

 

PART 3 · PARTIES TO THE AGREEMENT

6. Federal Agency (List office, bureau of organizational unit which is party to the agreement) 7. State or Local Government (Identify the government agency)

8. Is assignment being made through a faculty fellows program?
If “YES”, give name of program.
YES
NO

 

PART 4 · POSITION DATA

A · Position Currently Held
9. Employment Office Name and Address (Street, City, State and ZIP code) 10. Employee's Position Title 11. Office Telephone Number (Include the Area Code)

12. Immediate Supervisor (Name and Title)

B · Type of Current Appointment
13. Federal Employee (Check appropriate box) 14. State and Local Employees
Career Competitive
Other (Specify)
Grade Level State or Local Annual Salary Original Date Employed by the State or Local Government (Month, Day, Year)

C · Position To Which Assignment Will Be Made
15. Employment Office Name and Address (Street, City, State and ZIP code) 16. Employee's Position Title 17. Office Telephone Number. (Include the Area Code)

18. Immediate Supervisor (Name and Title)

 

PART 5 · TYPE OF ASSIGNMENT

19. Check Appropriate Boxes 20. Period of Assignment (Month, Day, Year)
On detail from a Federal agency
On leave without pay from a Federal agency Full Time
On detail to a Federal Agency Part Time
On appointment in a Federal agency Intermittent
From To
PART 6 · REASON FOR MOBILITY ASSIGNMENT

21. Indicate the reasons for this mobility assignment and discuss how the work will benefit the participating governments. In addition, indicate how the employee will be utilized at the completion of the assignment.
 

 

 

 

 

 
PART 7 · POSITION DESCRIPTION

22. List the major duties and responsibilities to be performed while on the mobility assignment.
 

 

 

 

 

 

 

PART 8 · EMPLOYEE BENEFITS

23. Rate of Basic Pay During the Assignment 24. Special Pay Conditions (Indicate any conditions that could increase the assigned employee's compensation during the assignment period)
 

25. Leave Provisions (Indicate the annual and sick leave benefits for which the assigned employee is eligible. Specify the procedure for reporting, requesting and recording such leave)
 

 

 

 
PART 9 · FISCAL OBLIGATIONS

Identify, where appropriate, the office to which invoices and time and attendance records should be sent.
26. Federal Agency Obligations (If paying more than 50 percent of a Federal employee's salary beyond a 6-month period, specify rationale for cost-sharing decision.) 27. State or Local Government Agency Obligations
 

 

 

 

 

 

 

PART 10 · CONFLICTS OF INTEREST AND EMPLOYEE CONDUCT

28. Applicable Federal, State or Local conflict-of-interest laws have been reviewed with the employee to assure that conflict-of-interest situations do not inadvertently arise during this assignment.
29. The employee has been notified of laws, rules and regulations, and policies on employee conduct, which apply to him/her while on this assignment.

 

PART 11 · OPTIONS

30. Indicate coverage “N/A,” if not applicable 31. State or Local Agency Benefits. (Indicate all State employee benefits that will be retained by the State or local agency employee being assigned to a Federal agency. Also, include a statement certifying coverage in all State and local employee benefit programs that are elected by the Federal employee on leave without pay from a Federal agency to a State or local agency.)
A. Federal Employees Group Life Insurance
Covered
N/A
B. Federal Civil Service Retirement
Covered
N/A
C. Federal Employee Health Benefits
Covered
N/A
32. Other Benefits (Indicate any other employee benefits to be made part of the agreement)
 

 

 

 

 
PART 12 · TRAVEL AND TRANSPORTATION EXPENSES AND ALLOWANCES

33. Indicate (1) Whether the Federal agency or State or Local Agency will pay travel and transportation expenses to, from, or during the assignment as specified in Chapter 334. of the Federal Personnel Manual, and (2) which travel and relocation expenses will be included.
 

 

 

 

 

 
PART 13 · APPLICABILITY OF RULES, REGULATIONS AND POLICIES

34. Check Appropriate Boxes
A. The rules and policies governing the internal operation and management of the agency to which my assignment is made under this agreement will be observed by me.
B. I have been informed that my assignment may be terminated at any time at the option of the Federal agency or the State or local government.
C. I have been informed that any travel or transportation expenses covered from Federal agency appropriations may be recoverable as a debt due to the United States, if I do not serve until the completion of my assignment (unless terminated earlier by either employer) or one year, whichever is shorter.
D. I have been informed of applicable provisions should my position with my permanent employer become subject to a reduction-in-force procedure.
E. I agree to serve in the Civil Service upon the completion of my assignment for a period equal to that of my assignment. Should I fail to serve the required time, I have been informed that I will be liable to the United States for all expenses (except salary) of my assignment. (For Federal employees only)

PART 14 · CERTIFICATION OF ASSIGNED EMPLOYEE

In signing this agreement, I certify that I understand the terms of this agreement and agree to the rules, regulations and policies as indicated in Part 13 above.
35. Location of Assignment (Name of Organization) 36. Date (Month, Day, Year)
  From To

37. Signature of Assigned Employee 38. Date of Signature (Month, Day, Year)

 

PART 15 · CERTIFICATION OF APPROVING OFFICIAL

In signing this agreement, we certify that:
– the description of duties and responsibilities is current and fully and accurately describes those of the assigned employee;
– this assignment is being entered into to serve a sound, mutual public purpose and not solely for the employee's benefit;
– at the completion of this assignment, the participating employee will be returned to the position he or she occupied at the time this agreement was entered into or a position of like seniority, status and pay.

State or Local Government Agency Federal Agency
39. Signature of Authorizing Officer 40. Signature of Authorizing Officer

41. Date of Signature (Month, Day, Year) 42. Date of Signature (Month, Day, Year)

43. Typed Name and Title 44. Typed Name and Title

PRIVACY ACT STATEMENT

Sections 3373 and 3374, Assignment of Employees To or From State or Local Governments, of Title 5, U.S. Code, authorizes collection of this information. The data will be used primarily to formally document and record your temporary assignment to or from State or local government, institution of higher education, Indian tribal government, or other eligible organization. This information may also be used as a legal basis for personnel and financial transactions, to identify you when requesting information about you, e.g., from prior employers, educational institutions, or law enforcement agencies, or by State, local, or Federal taxing agencies. Solicitation of your Social Security Number (SSN) is authorized by Executive Order 9397, which permitted use of the SSN as an identifier of individual records maintained by Federal agencies. Furnishing your SSN or any other data requested is voluntary. However, failure to provide any of the requested information may result in your being ineligible for participation in the Intergovernmental Assignment Program.
 

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last updated: 01/04/10

 

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