Form Hud-58-A - Clearance For Separation Of Employee - 2000


Clearance for Separation
U.S. Department of Housing
and Urban Development
of Employee
Office of Human Resources
For Headquarters Use Only.
See page 2 for Administrative Clearances
Part I. Request for Clearance
(To be completed by Administrative Officer or equivalent)
Instructions for Administrative Officer or Equivalent:
Initiate this form 5 days prior to an employee's separation. Advise the separating employee on local procedures for the clearance process.
Ensure that the employee signs this form in Part II and that the form is forwarded to the Servicing Human Resources Office before the employee
1. Name of Employee
2. Social Security Number
3. Date of Separation (mm/dd/yyyy)
4. Organization
5. Forwarding Address
6. Type of Separation
7. Office Door Keys
Leaving Federal Service
Transferring to Another Agency
None Issued
8. Relocation Services Agreement
Not Completed
Not Applicable
Note: If an agreement is not completed and the employee is not transferring to another agency, funds must be recovered unless the employee has obtained
a waiver by the Assistant Secretary for Administration. If funds should be recovered, explain in Part III and indicate the dollar amount to be collected.
9. Leave Record (HUD-260) must be attached to this form.
Are there any discrepancies between PC-TARE and the NFC database?
Note: For unresolved discrepancies requiring a change to the NFC database, the Leave Correction Memorandum must also be attached.
Signature of Administrative Officer or Equivalent
Telephone Number
Date (mm/dd/yyyy)
Part II. Employee Certification
Instructions for Employees:
To avoid delays in final salary payments, this form must be completed and returned to your Administrative Officer or equivalent before you
You must clear every item applicable to you and then sign the employee certification below.
If you want your final salary payments sent to an address other than where your salary payments are currently being sent, complete
and attach an AD-349, Declaration Sheet , to this form.
Employee Certification: I certify that I have no Government property, computer software/hardware, keys, records or official documents,
including classified material issued or furnished by the Department of Housing and Urban Development.
I understand that the depreciated value of Government property charged to me may be withheld from monies due me if the loss or theft of or
damage to such property is determined by a Board of Survey and the Reviewing Official to be due to negligence or intent on my part.
Signature of Employee
Date (mm/dd/yyyy)
Part III. Uncollected Indebtedness
Instructions for the Clearance Official: If any chargeable item listed in Part I or Part IV was not accounted for or returned, indicate the dollar
value of the unaccounted item to be collected from the employee's final salary payments.
Signature of Clearance Official
Signature of Clearance Official
Signature of Clearance Official
form HUD-58-A (12/2000)
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Previous editions are obsolete


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