Fillable Printable Separation Clearance Certificate
Fillable Printable Separation Clearance Certificate
Separation Clearance Certificate
LEAVING FEDERAL SERVICE TRANSFER TO ANOTHER AGENCY TRANSFER WITHIN COMMERCE
1. CD–43, CD–128 OR OTHER OFFICIAL IDENTIFICATION.
CLEARED BY: Signature Date
Telephone
2.
DOOR KEYS AND/OR ELECTRONIC DOOR KEY CARDS.
3. GOVERNMENT TRAVEL CHARGE
6. PERSONALLY CHARGED PROPERTY.
7. TRANSPORTATION REQUESTS (Cleared with servicing ASC or MSC).
4. TELEPHONE CREDIT CARDS.
TYPE OF SEPARATION:
CHANGE IN TELEPHONE DIRECTORY INFORMATION SUBMITTED NOT REQUIRED
LEAVE AUDIT, AD–717 ATTACHED NOT REQUIRED
U.S. DEPARTMENT OF COMMERCE
SEPARATION CLEARANCE CERTIFICATE
INSTRUCTIONS FOR SUPERVISORS:
Initiate this form normally one week before an employee’s separation, according to your Departmental Office or operating unit’s internal procedures.
the separating employee on the clearance process. separating
employee and check those blocks in Section III.
INSTRUCTIONS FOR EMPLOYEES:
TO AVOID DELAY IN FINAL PAYCHECK this form must be completed
and submitted to your servicing personnel office before your final
paycheck, lump sum leave payment or any other monies due you can be
released.
in Section III.
Follow your Departmental Office or operating unit’s clearance procedure.
Clear your servicing personnel office last, normally on your last work day.
If you want your final paycheck sent to an address other than where your
paychecks are currently being sent, complete and attach the AD-349 to
this clearance form.
SECTON I.—TO BE COMPLETED BY IMMEDIATE SUPERVISOR
FORM CD–126
(REV. 11-00)
DAO 202–299
NAME OF SEPARATING EMPLOYEE EFFECTIVE DATE OF SEPARATION DATE INITIATED
FULL NAME OF ORGANIZATION
REQUEST FOR PERSONNEL ACTION, SF–52 SUBMITTED
INTERIM SUMMARY PERFORMANCE APPRAISAL, CD–396 ATTACHED NOT REQUIRED
Required when employee transfers to another position in the Department or another
Federal agency after serving in his/her position for 120 days or more during the appraisal cycle.
LUMP SUM LEAVE PAYMENT, AD–581 ATTACHED NOT REQUIRED
SUPERVISOR’S SIGNATURE
DATE TELEPHONE
SECTON II.—ADMINISTRATIVE CLEARANCES: (Required Clearances for All Employees)
5. IMPREST FUND PAYMENTS.
INSTRUCTIONS FOR CLEARANCE OFFICIALS:
Indicate clearance of chargeable items by signing the applicable block.
Above your signature in the applicable block note the reasons any
chargeable item was not accounted for or returned and indicate the dollar
value of unaccounted for items to be collected from the employee.
Sign (using full signature) and date the appropriate clearance block(s).
Include your phone number.
ATTACHED NOT REQUIRED
Reference: Time and Attendance Manual
Exhibits on Reports and Form Preparation–Part A
.
8.
TRAVEL ADVANCE.
Reference: Time and Attendance Manual
Exhibits on Reports and Form Preparation–Part
.
EARLIER VERSION OBSOLETE
Advise
Complete Section I, determine which OTHER CLEARANCES are appropriate for the
You must clear every item in Section II and any checked item(s)
C
(continue on reverse)
I certify that, except as otherwise indicated, I have no Government property, records or documents, including classified material issued or furnished by the Department of
Commerce or reproduced by me, and I am not otherwise indebted to the United States Government.
I certify that I have reviewed all the non-record documents (defined in DAO-205-3) that I plan to remove from the Department. None of these documents contain national
security information or other information afforded protection under various statutes or regulations, such as privacy information or trade secrets; relate to any pending or
contemplated civil, criminal, or administrative proceeding or other program activity where their release could prejudice the matter; if removed, would hinder the efficient,
continued functioning of an office or of my successor; if removed, would diminish the records or other documentary information needed for the official business of the
Department; if removed, would violate the confidentiality of any interest protected by law, such as national security, privacy, trade secrets; if removed, would exceed
normal administrative economies (i.e., impose an unreasonable cost or burden created by copying or removing the materials from the building); or if removed, would
unnecessarly expose, or risk exposing, to the public any internal deliberations, opinions, legal or policy advice, law enforcement materials, or other professional work-
product of any offier or employee of the Department. In addition, I understand that I must te official possessing authority under
Section 4 of DAO 205-12 before I will be permitted to remove any documents that would not normally be released to a third party under the Freedom of Information Act.
I received, read and understand the memorandum from the Office of General Counsel about the post employment restrictions under 18 U.S.C. 207.
CLEARED BY: Signature
SECTON IV.—EMPLOYEE CERTIFICATION
TelephoneDate
SECTON III.—OTHER CLEARANCES: (CLEAR ONLY IF CHECKED).
INVESTIGATIVE CREDENTIAL AND BADGE
OFFICIAL OR DIPLOMATIC PASSPORT
OFFICIAL PARKING PERMITS
(COMMERCE/LOCAL GOVERNMENT)
SECURITY DEBRIEFING/COURIER AUTHORIZATION, CD–75
FEMA SPECIAL FACILITY PASS
LIBRARY
LAW LIBRARY (LEXIS/NEXIS/WESTLAW/LEGISLATE)
COMPUTER ACCESS
CLASSIFIED/SENSITIVE INFORMATION
HAZARDOUS MATERIALS
CONTINUED SERVICE AGREEMENT—SF–182, TRAINING
CONTINUED SERVICE AGREEMENT—CD–150, RELOCATION
CLASSIFIED SECURITY CONTROL POINT
Cleared AD–58 released to NFC
Not Cleared NFC notified by:
AD–343 issued—Amount due $ Issued by:
Signature Date
FORMS GIVEN TO SEPARATING EMPLOYEE:
SF–8, UNEMPLOYMENT COMPENSATION SF–2810, HEALTH BENEFITS
SF–2803, RETIREMENT REFUND SF–2819, FEGLI–NOTICE OF CONVERSION
SECTON V.—SERVICING PERSONNEL OFFICE CLEARANCE
SIGNATURE DATE PRIVACY ACT STATEMENT. Your Social Security number is already part of the
Personnel and Payroll Information Systems: please include the number on this
form to help accurately identify
your records and expedite pay-
ments of any monies due you.
obtain clearance from the appropria
FORM CD–126 (REV. 11-00)
