Form Hud-58 - Clearance For Separation Of Employee - 2007 Page 2
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1
2Last Name:_____________________
First Name:_____________________
Last 5 SSN:_______________
Part IV. Administrative Clearances
Instructions for the Clearance Official: Indicate clearance of chargeable items by signing your name, date, and telephone number in
the appropriate blocks. Note in Part III the reasons why any chargeable item was not accounted for or returned and indicate the
dollar value of the unaccounted item to be collected from the employee’s final salary payments.
Item
Room
Cleared by (Signature)
Date
Telephone
1. Financial Disclosure Statement (SF-278)
2130
Office of Ethics
2. Procurement Official’s Certification
2130
Office of Ethics
3. Post-employment Memorandum
2130
Office of Ethics
4. Training Obligations Training Academy
2180
5. Student Loan Repayment Benefit
2182
6. Travel Advance & Travel Charge Card
3216
Office of CFO
7. Assistive Technology
4272
8. Special Computer Equipment
4272
(Blackberry, Air-card, Laptop, or Camera)
9. Computer Access (ID’s, Passwords, etc)
4280
IT, ADP Security Staff
10. Investigators Badge (FAIR HSG. ONLY)
5124
Return to FHEO ADMIN. OFFICER
11. Telephone Equipment (Cellular Phone,
5162
Pager, Calling Card) OAMS, Space
Management Division
12. Employee Exit Survey HUD-58-B
5250
13. COOP-Related Items, Emergency Team
6272
Radios, Emergency Prep Branch OSEP
14. Parking, Physical Security Branch,
6280
OSEP
15. Building Pass, PIV Branch, OSEP
6282
16. Security Termination Statement
6282
Personnel Security Branch, OSEP
17. Library Books and Periodicals
8141
18a. Records (Program Office) Program
Varies
Records Management Liaison Officer
18b. Records (Departmental Records
B-100
Officer) OAMS, Records & Directives
Branch –Must have signature on
18 a first
19. HUD Fitness Center (if a member)
B-122
20. Personally Charged Property OAMS,
B-137
Space Management Division
21. U.S. Government Bank Card
B-258
Office of Budget & Administrative Sprt.
22. Transit Subsidy
B-258
Office of Budget & Administrative Sprt.
23. Litigation Holds
Varies
(i.e., memo notifying employee that information in
electronic and paper form at related to a specific
court case must be kept due to potential litigation)
Associate General Counsel Who Sent
Litigation Hold
Previous editions are obsolete
Page 2 of 2
Form HUD -58-A
(09/2008)
To ensure accurate records, documents HUD 58 and HUD 58-A should be copied front to back
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