Standard
Form 52
Rev. 7/91
U.S. Office of Personnel
Management
FPM Supp. 296-33, Subch. 3 |
REQUEST FOR
PERSONNEL ACTION |
|
| PART
A- Requesting Office (Also complete Part B, Items 1, 7-22, 32, 33,
36 and 39 |
| 1.
Actions Requested
|
2.
Request Number |
| 3.
For Additional Information Call (Name and Telephone Number)
|
4.
Proposed Effective Date |
| 5.
Action Requested By (Typed Name, Signature and Request Date
|
6.
Action Authorized By (Typed Name, Title, Signature, and
Concurrence Date |
| PART
B- For Preparation of SF 50 (Use only codes in FPM Supplement
292-1. Show all dates in month-day-year order. |
| 1.
Name (Last, First, Middle)
|
2.
Social Security |
3.
Date of Birth |
4.
Effective Date |
| FIRST
ACTION |
SECOND
ACTION |
| 5-A
Code
|
5-B
Nature of Action |
6-A
Code |
6-B
Nature of Action |
| 5-C
Code
|
5-D
Legal Authority |
6-C
Code |
6-D
Legal Authority |
| 5-E
Code
|
5-F
Legal Authority |
6-E
Code |
6-F
Legal Authority |
| 7.
FROM: Position Title and Number
|
15.
TO: Position Title and Number |
| 8.
Pay Plan
|
9.
Occ. Code |
10.
Grade or Level |
11.
Step or Rate |
12
Total Salary |
13
Pay Basis |
16.
Pay Plan |
17.
Occ Code |
18.
Grade or Level |
19.Step
or Rate |
20
Total Salary |
21.
Pay Basis |
| 12A.
Basic Pay
|
12B.
Locality Adj |
12C>
Adj. Basic Pay |
12D.
Other Pay |
20A.
Basic Pay |
20B.
Locality Adj |
20C>
Adj. Basic Pay |
20D.
Other Pay |
| 14.
Name and Location of Position's Organization |
22.
Name and Location of Position's Organization |
| EMPLOYEE
DATA |
| 23.
Veterans Preference
| 1 -
None
|
3 -
10-Point/Disability |
5 -
10-Point/Other |
| 2 -
5-Point
|
4 -
10-Point/Compensable |
6 -
10-Point/Compensable/30% |
|
24.
Tenure
| 0 -
None
|
2 -
Conditional |
| 1-
Permanent
|
3 -
Indefinite |
|
25.
Agency Use |
26.
Veterans Preference for RIF
|
| 27.
FEGLI
|
28.
Annuitant Indicator |
29.
Pay Rate Determinant |
| 30.
Retirement Plan
|
31.
Service Comp Date (Leave) |
3-2
Work Schedule |
33.
Part Time Hours Per Biweekly Pay Period |
| POSITION
DATA |
| 34.
Position Occupied
|
35.
FLSA Category E - Exempt N - Nonexempt |
36.
Appropriation Code |
37.
Bargaining Unit Status |
| 38.
Duty Station Code
|
39.
Duty Station (City - County - State or Overseas Location) |
| 40.
AGENCY DATA IA POS
|
41.
NEW POSITION |
42.
REGRADED POSITION |
43.
VICE |
44.
QUALIFICATION STANDARDS USED |
| 45.
Educational Level
|
46.
Yr. Degree Attained |
47.
Academic Discipline |
48.
Functional Class |
49.
Citizenship 1. USA 8 - Other |
50.
Vietnam Era Vet Y- Yes N - No |
51.
Supervisory Status |
| PART
C - Reviews and Approvals (Not to be used by requesting office.) |
| 1.
Office/Function
|
Initials/Signature |
Date |
1.
Office/Function |
Initials/Signature |
Date |
| A.
Position Authorized |
D.
English Language Proficiency |
| B.
Classification |
E.
Drug Testing Position |
| C.
Placement |
F. |
| 2.
Approval: I certify that the information entered on this form is
accurate and that the proposed action is in compliance with
statutory and regulatory requirements. |
Signature |
Approval
Date |
| PART
D - Remarks by Requesting Office |
(Note
to Supervisors: Do you know of additional or conflicting reasons
for the employee's resignation/retirement?
If “YES”, please state these facts on a separate sheet and
attach to SF 52)
|
|
| PART
E - Employee Resignation/Retirement |
|
Privacy Act
Statement |
| You
are requested to furnish a specific reason for your resignation or
retirement and a forwarding address. Your reason may be considered
in any future decision regarding your re-employment in the Federal
service and may also b used to determine your eligibility for
unemployment compensation benefits. Your forwarding address will
be used primarily to mail you copies of any documents you should
have or any pay or compensation to which you are entitled.
This information is requested under authority of sections 301,
3301, and 8506 of title 5, U.S. Code. Sections 301 and 3301
authorize OPM and agencies to issue regulations with regard to
employment of individuals in the Federal service and their
records, while section 8506 requires agencies to furnish the
specific reason for termination of Federal service to the
Secretary of Labor or a State agency in connection with
administration of unemployment compensation programs.
The furnishing of this information is voluntary; however,
failure to provide it may result in your not receiving: (1) your
copies of those documents you should have; (2) pay or other
compensation due you; and (3) any unemployment compensation
benefits to which you may be entitled. |
| 1.
Reasons for Resignation/Retirement (NOTE: Your reasons are used in
determining possible unemployment benefits. Please be specific and
avoid generalizations. Your resignation/retirement is effective at
the end of the day - midnight - unless you specify otherwise.
|
| 2.
Effective date
|
3.
Your Signature |
4.
Date Signed |
5.
Forwarding Address (Number, Street, City, State, ZIP Code) |
| PART
F - Remarks for SF 50 |
|
|
