HR - STATEMENT OF PRIOR FEDERAL CIVILIAN AND MILITARY SERVICE - (SANITIZED)

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0005382558
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 24, 2015
• Document Release Date: January 31, 2011
• Case Number: F-2009-00333
• Publication Date: September 8, 1969

APPROVED FOR
RELEASE[] DATE:
04-Aug-201 0
STANDARD FORM 144
R. AUGUST 1966
STATEMEN
JF PRIOR FEDERAL CIVILIAN AND MILITa
r SERVICE
.
r,
U.S.
CIVIL SERVICE COMMISSION
FPM Supp. 296-31
IMPORTANT: This form Is used only to establish creditability of service, which is otherwise not verified in the Official Personnel Folder, for leave
and reduction in force purposes. The employee will complete Part I and the Personnel Office Parts II and Ill. When this form is
used as a cumulative record or the employee's affidavit is used in the absence of a verified record, it must be filed on the right side
of the Official Personnel Folder.
PART I.-EMPLOYEE'S STATEMENT.
1. NAME (Last, first, initial) ^ Mr. Mrs. ^ Miss
2. BIRTH DATE (Mo., day, yr)
p4t-L\4, 4N N L K.
, c.., rP~a
3. LIST THE FOLLOWING INFORMATION ABOUT ANY CLAIMED FEDERAL OR DISTRICT OF COLUMBIA SERVICE YOU HAVE HAD WHICH HAS NOT
YET BEEN VERIFIED. (Do not include military service.) IF ANY OF THIS SERVICE WAS PART-TIME, WAE, OR INTERMITTENT, NOTE THIS
UNDER "TYPE OF APPOINTMENT." ...
NAME AND LOCATION OF AGENCY
FROM
TO
TYPE OF APPOINTMENT
YEAR
MONTH
DAY
YEAR
MONTH
DAY
(If known)
4. LIST PERIODS OF ANY CLAIMED ACTIVE SERVICE YOU HAVE HAD IN ANY BRANCH OF THE ARMED FORCES OF THE UNITED STATES,
INCLUDING ACTIVE DUTY AS A RESERVIST, WHICH HAS NOT YET BEEN VERIFIED. (Also list Merchant Marine service, if it interrupted serv.
ice shown in Item 3.)
BRANCH
FROM
TO
DISCHARGE
YEAR
MONTH
DAY
YEAR
MONTH
DAY
(Hon. Or Dishon.)
5. DURING PERIODS OF EMPLOYMENT SHOWN IN ITEM 3, DID YOU HAVE A TOTAL OF MORE THAN 6 MONTHS
ABSENCE WITHOUT PAY DURING ANY ONE CALENDAR YEAR? (if YES, list following information.) ^ YES NO
FROM
TO
TOTAL
Furl
Susp.
A
W.O.L.)
W
P
TYPE IF KNOWN (L
O
,
.
.
.
.,
.,
.
YEAR
MONTH
DAY
YEAR
MONTH
DAY
YEARS
MONTHS
DAYS
6. DO YOU CLAIM ANY TYPE OF VETERAN PREFERENCE WHICH HAS NOT BEEN VERIFIED? ^ Yes No If "Yes," check one
of the following statements if it applies to you: ^ I CLAIM PREFERENCE AS THE WIFE OF A DISABLED VETERAN.
^ I CLAIM PREFERENCE AS THE MOTHER OF A DECEASED OR DISABLED VETERAN.
^ I CLAIM PREFERENCE AS THE UNREMARRIED WIDOW OF A VETERAN.
7. TO BE EXECUTED BEFORE A NOTARY PUBLIC OR OTHER PERSONS AUTHORIZED TO ADMINISTER OATHS.
I swear (or affirm) that the above statements are true to the best of my knowledge and belief.
Date: 8 SEPTEMBER 1969
(Signature)
Subscribed and sworn to (or 8th SEPTEMBFF~ 69 WASHINGTON
D
C
"'
.
19 at
?
, affirmed) before me on this day of
(Month)
SEAL
NOTE: If oath is taken before a Notary Public, the date of expiration Is o mission must De sio n.
 TO BE COMPLETED BY THE PERSONNEL OFFICE
PART II.-DETERMINATION OF CREDITABLE SERVICE AND SERVICE COMPUTATION DATE FOR LEAVE PURPOSES, (See FPM, Chapter 630
and Supplement 296-31, Appendix B.) NOTE: For year below, show only last two numbers, for months show numerical equivalent.
CREDITABLE SERVICE
(List only periods that are creditable for
(a)
Appointment date
(b)
Separation date
NONCREDITABLE SERVICE
(List noncreditable civilian r military service
leave purposes)
YEAR
MONTH
DAY
YEAR
MONTH
DAY
included in dates to the left)
ENTRANCE ON DUTY DATE
TOTAL NONCREDITABLE SERVICE
TOTAL
(a)
(b)
SERVICE COMPUTATION DATE (a)-(b)
PART Ill.-DETERMINATION OF CREDITABLE SERVICE AND SERVICE DATE FOR REDUCTION IN FORCE PURPOSES. (Complete only in cases
where the amount of creditable service for reduction in force purposes differs from the amount creditable for leave purposes.) (See
FPM Chapter 351 and Supplement 296-31, Appendix B.)
CREDITABLE SERVICE
(a)
Appointment date
(b)
Separation date
NONCREDITABLE SERVICE
(List noncreditable civilian or military service
YEAR
MONTH
DAY
YEAR
MONTH
DAY
included in the additional service only)
SERVICE COMPUTATION DATE (From Part II)
ADDITIONAL SERVICE CREDITABLE FOR RIF ONLY
TOTAL NONCREDITABLE SERVICE
TOTAL
a)
(b)
SERVICE DATE (a)-(b)'
"Enter as the "Service Date" on Standard form 7, 'Service Record."
REMARKS: