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Fillable Printable OF 69

Fillable Printable OF 69

OF 69

OF 69

OF 69 # (REV. 2-89)
U.S. Office of Personnel Management
FPM Chapter 334
Assignment Agreement
Title IV of the Intergovernmental Personnel Act of 1970 (5 U.S.C. 3371-3376)
This agreement constitutes the written record of the obligations and
responsibilities of the parties to a temporary assignment arranged
under the provisions of the Intergovernmental Personnel Act of 1970.
The term "State or local government," when appearing in this
form, also refers to an institution of higher education, and
Indian tribal government, and any other eligible organization.
Copies of the completed and signed agreement should be
retained by each signatory.
Within 30 days of the effective date of the assignment, two copies of this
form must be sent to:
U.S. Office of Personnel Management
Personnel Mobility Program
Staffing Operations Division/CEG
1900 E street, NW
Washington, D.C. 20415
Procedural questions on completing the assignment agreement form or on
other aspects relating to the mobility program should be addresses to either
mobility program coordinators in each Federal agency or to the staff of the
Personnel Mobility Program is the U.S. Office of Personnel Management.
PART 1 - NATURE OF THE ASSIGNMENT AGREEMENT
PART 2 - INFORMATION ON PARTICIPATING EMPLOYEE
1. Check Appropriate Box
2. Name (Last, First, Middle)
3. Social Security Number
4. Home Address (Street, City, State, Zip Code)5.- A. Have you ever been on a mobility assignment?
5.- B. If "YES", date of each assignment (Month and Year)
New AgreementModificationExtension
YESNO
PART 3 - PARTIES TO THE AGREEMENT
6. Federal Agency (List office, bureau or organizational unit which is party to
the agreement)
7. State or Local Government (Identify the governmental agency)
8. Is assignment being made through a faculty fellows program?
If "YES", give name of the program.
YESNO
PART 4 - POSITION DATA
A - Position Currently Held
9. Employment Office Name and Address (Street, City, State and ZIP Code)10. Employee's Position Title11. Office Telephone Number
(Include the Area Code)
12. Immediate Supervisor (Name and Title)
B - Type of Current Appointment
13. Federal Employees (Check appropriate box.)
Career Competitive
Other (Specify):
Grade Level
14. State and Local Employees
State or Local Annual Salary
Original Date Employed by the
State or Local Government (Month,
Day, Year)
C - Position To Which Assignment Will Be Made
15. Employment Office Name and Address (Street, City, State and ZIP Code)
16. Assignee's Position Title17. Office Telephone Number
(Include the Area Code)
18. Immediate supervisor (Name and Title)
50 69 - 105Previous edition is usable
INSTRUCTIONS
From
To
19. Check Appropriate Boxes
PART 5 - TYPE OF ASSIGNMENT
On detail from a Federal agency
On leave c from a Federal agency
On detail to a Federal agency
On appointment in a Federal agency
Full Time
Part Time
Intermittent
20. Period of Assignment (Month, Day, Year)
FromTo
PART 6 - REASON FOR MOBILITY ASSIGNMENT
21. Indicate the reasons for the mobility assignment and discuss how the work will benefit the participating governments. In addition, indicate how the
employee will be utilized at the completion of this assignment.
PART 7 - POSITION DESCRIPTION
22. List the major duties and responsibilities to be performed while on the mobility assignment.
PART 8 - EMPLOYEE BENEFITS
23. Rate of Basic Pay During Assignment
24. Special Pay Conditions (Indicate any conditions that could increase the
assigned employee's compensation during the assignment period)
25. Leave Provisions (Indicate the annual and sick leave benefits for which employee is eligible. Specify the procedures for reporting, requesting and
recording such leave.)
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Identify, where appropriate, the office to which invoices and time and attendance records should be sent.
26. Federal Agency Obligations (If paying more than 50 percent of a
Federal employee's salary beyond a 6-month period, specify rationale
for cost-sharing decision.)
PART 9 - FISCAL OBLIGATIONS
27. State or Local Government agency Obligations
PART 10 - CONFLICTS OF INTEREST AND EMPLOYEE CONDUCT
28. Applicable Federal, State or local conflict-of-interest laws have been reviewed with the employee to assure that conflict-of-interest situations do
not inadvertently arise during this assignment.
29. The employee has been notified of laws, rules and regulations, and policies on employee conduct which apply to him/her while on this
assignment.
PART 11 - OPTIONS
30. Indicate coverage "N/A", if not applicable.
A. Federal Employees Group Life Insurance
Covered
N/A
B. Federal Civil Service Retirement system or federal Employees Retirement
System
CoveredN/A
N/A
Covered
C. Federal employee Health Benefits
31. State or Local Agency Benefits (Indicate all State employee benefits that
will be related by the State or local agency employee being assigned to a
Federal agency. Also include a statement certifying coverage in all State
and local employee benefit programs that are elected by Federal
employee on leave without pay from the Federal agency to a State or
local agency.)
33. Indicate: (1) Whether the Federal agency or State or local agency will pay travel and transportation expenses to, from, and during the assignment as
specified in Chapter 3344 of the Federal Personnel Manual, and (2) which travel and relocation expenses will be included.
32. Other Benefits (Indicate any other employee benefits to be made part of this agreement)
PART 12 - TRAVEL AND TRANSPORTATION
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PART 13 - APPLICABILITY OF RULES, REGULATIONS AND POLICIES
34. Check Appropriate Boxes.
A. The rules and policies governing the internal operation and
management of the agency to which my assignment is made
under this agreement will be observed by me.
B. I have been informed that my assignment may be
terminated at any time at the option of the Federal agency or
the State or local government.
C. I have been informed that any travel and transportation expenses
covered from Federal agency appropriations may be recoverable as a
debt due the united states, if I do not serve until the completion of my
assignment (unless terminated earlier by either employer) or one
year, whichever is shorter.
PART 14 - CERTIFICATION OF ASSIGNED EMPLOYEE
In signing this agreement , I certify that I understand the terms of this agreement and agree to the rules, regulations and policies as indicated in Part 13 above.
D. I have been informed of applicable provisions should my
position with my permanent employer become subject to a
reduction-in-force procedure.
E. I agree to serve in the Civil Service upon the completion of my
assignment for a period equal to that of my assignment. Should I
fail to serve the required time, I have been informed that I will be
liable to the United States for all expenses (except salary) of my
assignment. (For Federal Employees only).
35. Location of Assignment (Name of Organization)
37. Signature of Assigned Employee
36. Date (Month, Day, Year)
FromTo
38. Date of Signature (Month, Day, Year)
PART 15 - CERTIFICATION OF APPROVING OFFICIALS
In signing this agreement, we certify that;
- the description of duties and responsibilities is current and fully and accurately describes those of the assigned employee;
- this assignment is being entered in to to serve a sound, mutual public purpose and not solely for the employee's benefit;
- at the completion of the assignment, the participating employee will be returned to the position he or she occupied at the time this agreement was entered
into or a position of like seniority, status pay.
State or Local Government Agency
39. Signature of Authorizing Officer
41. Date of Signature (Month, Day, Year)
43. Typed Name and Title
Federal Agency
40. Signature of Authorizing Officer
42. Date of Signature (Month, Day, Year)
44. Typed Name and Title
PRIVACY ACT STATEMENT
Sections 3373 and 3374, Assignment of Employees To or From State or
Local Governments, of Title 5, U.S. Code, authorizes collection of this
information. The data will be used primarily to formally document and record
your temporary assignment to or from a State or local government, institution
of higher education, Indian tribal government, or other eligible organization.
This information may also be used as the legal basis for personal and
financial transactions, to identify you when requesting information about you,
e.g., from prior employers, educational institutions, or law agencies, or by
State, local, or Federal income taxing agencies.
Solicitation of your Social Security Number (SSN) is authorized by
Executive Order 9397, which permitted by use of the SSN as an identifier
of individual records maintained by Federal agencies. Furnishing your
SSN or any other data requested is voluntary. However, failure to prove
any of the requested information may result in your being ineligible for
participation in the Intergovernmental Assignment Program.
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