Attachment A (Standard Form 52) - Request For Personnel Action Page 2

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SF 52 (Reverse)

PART D -- Remarks by Requesting Office

(Note to Supervisors: Do you know of additional or conflicting reasons for the employee's resignation/retirement?

Yes

If "YES", please state these facts on a seperate sheet and attach to SF 52.)

Reason for ABSENT: ___________________________________ Employee Supervised by: _________________________________

If ABSENT for Military Duty - Attach a copy of the orders &

Employee supervises the following employees: ___________________

Select from the following Federal Benefits Options Below

____________________________ ____________________________

ANNUAL LEAVE: 1) PAID IN A LUMP SUM PAYMENT

____________________________ ____________________________

2) WISHES BALANCE TO REMAIN

Work Schedule

S M T W Th F S

Total leave outline:

1ST WEEK

8 8 8 8 8

MIL LEAVE: FROM _________ THRU ________

2ND WEEK

8 8 8 8 8

ANNUAL LEAVE: FROM ________ THRU ________

ABSENT: FROM ________ THRU ________

PART E -- Employee Resignation/Retirement

PRIVACY ACT STATEMENT

You are requested to furnish a specific reason for your resignation or retirement

regulations with regard to employment of individuals in the Federal service and

and a forwarding address. Your reason may be considered in any future decision

their records, while section 8506 requires agencies to furnish the specific reason

regarding your re-employment in the Federal service and may also be used to

for termination of Federal service to the Secretary or Labor or a State agency in

determine your eligibility for unemployment compensation benefits. Your

connection with administration of unemployment compensation programs.

forwarding address will be used primarily to mail you copies of any documents

The furnishing of this information is voluntary; however, failure to provide it may

you should have or any pay or compensation to which you are entitled.

result in your not receiving: (1) your copies of those documents you should have;

This information is requested under authority of sections 301, 3301, and 8506 of

(2) pay or other compensation due you; and (3) any unemployment compensation

title 5, U.S. Code. Sections 301 and 3301 authorize OPM and agencies to issue

benefits to which you may be entitled.

1. Reason 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.)

IF ABSENT FOR MILITARY DUTY - ATTACH COPY OF ORDERS & SELECT FEHB/FEGLI OPTIONS:

FEHB: 1) I do not have Federal Employees Health Benefits (FEHB).

2) I request my Federal Employees Health Benefits (FEHB) be continued during the period of my military duty

(maximum 24 months).

3) I request my Federal Employees Health Benefits (FEHB) be terminated (1st day of military orders)

FEGLI: 1) I do not have Federal Employees Group Life Insurance (FEGLI)

2) I request my Federal Employees Group Life Insurance (FEGLI) be continued during my period of military duty

(maximum 12 months)

3) I request my Federal Employees Group Life Insurance (FEGLI) be terminated (1st day of military orders)

SIGNED: ____________________________________________

2. Effective Date