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SEC RJEi (When F' fed In) (b) (3) (b) (6) NOTIFICATION OF PERSONNEL ACTION 1. SERIAL NUMBER 2. NAME (LAST-FIRST-MIDDLE) (~ :1: I._ I_ ri P'i (w1 N'T' l~i L I_. I_ L:: 3. NATURE OF PERSONNEL ACTION I'til:. ~.~I.{~?~I?~ ~ 4. EFFECTIVE DATE 5. CATEGORY OF EMPLOYMENT (~ Ll l.. t.! I~ ((~ I~ Y) tJ N )<1 I?~. ('t f...i. !~ fi I~ f .L l'; L- i~ I~. IV Y Mo. DA. YR. A ~! LI lCl 1: S ~ ~ T I_.:C '~(' Y fa'Y' ~i ?T ~' ~'I :I. ~' ~ ? ? l~ i::: (~ L? I._ !t 7. FAN AND NSCA 8. CSC OR OTHER LEGAL AUTHORITY 6. FUNDS' 1''1_. 3{:i"'.Ot ,~`~ ~ wl:::~:'~~ ',:1:~.~ 9. ORGANIZATIONAL D N ~kx TtL1A~gl=l~ TL"E: U1= I_CII~T~T'1L~ gE'i~TCk t7f~ 7'H~: T:-11~kC?1'UI'; ~t~{` t+ pp~~ ( W~.~.}I"1a p LIaS.: a 11 12. POSITION NUMBER 13. SERVICE DESIGNATION S~.CtJFi:l:"fY t71~'I~ Tt:i:::h 14. CLASSIFICATION SCHEDULE (GS, WG, etc.) 15. OCCUPATIONAL SERIES 16. TEP 17. SALARY OR RATE x.7,17 i ~ l7 :~:w~iz.>~~:~ 18. REMARKS SPACE BELOW FOR EXCLUSIVE USE OF THE OFFICE OF PERSONNEL 19, ACTION 20. Employ- CODE C d 21. OFFICE CODING 22. STATION 23. 24. Hdgirs. 25. DATE OF BIRTH 26. DATE OF GRADE 27. DATE OF LEI o e NUMERIC ALPHABETIC CODE Code MO. DA, YR. MO. DA YR. MO. DA. YR. 28. NTE EXPIRES 29, SPECIAL 30. RETIREMENT DATA 31. SEPARATION 32. Correction/Cancellation Data 33. SECURITY 34 SEX MO. DA. YR. REFERENCE 2_CA CODE DATA CODE TYPE MO. DA YR REQ. NO. . . EOD DATA 3 -FICA ` tt ? I> {~'V ~~"~4~ 5 -NONE ? 35. VET. PREFERENCE 36. SERV. COM P. DATE 37. LONG. COMP. DATE 38. CAREER CATEGORY 39. FEGLI /HEALTH INSURANCE 40. SOCIAL SECURITY NO. CODE 0 -NONE 1 -SPT MO. DA. YR. MO. DA. YR. CAR. RESV. - - CODE CODE 0 -WAIVER HEALTH INS. CODE . 2 - 10 PT. _ GOV. AMP. 1-YES 41. PREVIOUS CIVILIAN GOVERNMENT SERVICE 42. LEAVE CAT . 43. FEDERAL TAX DATA 44. STATE TAX DATA coDE 0 - NO PREVIOUS SERVICE CODE FORM EXECUTED CODE NO. TAX EXEMPTIONS FORM EXECU7ED CODE NO. TAX STATE CODE 1 - NO BREAK IN SERVICE 1 -YES I - YE$ EXEMP. 2 -BREAK IN SERVICE (LESS THAN 3 YRS.) 2 - NO 2 - NO 3 -BREAK IN SERVICE (MORE THAN 3 YRS.) SIGNATURE OR`(1THER >',UTH'~NTICA;{;,N APPROVED FOR RELEASE ~~~ DATE: NOV 2007 30Dec ??? ~ f --- -..~_____ FORM 1150 Use Previous 5-74 Mfg 10-74 Edition