OFFICE OF THE CHIEF ADMINISTRATIVE
OFFICER
U.S. HOUSE OF REPRESENTATIVES
____________________________________________________________________________
CHECK-OUT FORM:
Employee Name: ________________________________ Office:
_______________________
Position Title: __________________________________
Position #: ____________________
If the Check-Out process for a particular item is not
applicable to your position, your supervisor should mark
that item "NA" and initial.
Any questions regarding this procedure should be referred
to the Human Resources' Office of Policy and
Administration, extension 52926.
Upon completion of this form, your signature is required
as verification of accuracy.
PLEASE NOTE: YOUR FINAL HOUSE COMPENSATION WILL NOT BE
ISSUED UNTIL THIS FORM HAS BEEN SATISFACTORILY COMPLETED
AND RETURNED TO THE HUMAN RESOURCES' OFFICE OF POLICY AND
ADMINISTRATION, ROOM 719, O'NEILL HOUSE OFFICE BUILDING.
_________________________________________________________________
SUPERVISOR, verify that the employee has cleared all
check-out procedures and office requirements to include
such items as:
1) Payroll has been notified of separation date and time
and attendance has been verified
Coordinate with Office of Finance,
Office of Payroll, Rm. 263, CHOB, Ext. 56514 Sign Off:
__________ Date: __________
2) All portable equipment has been returned and accounts
closed (i.e. Pagers,
Cellular Phones, Lap-Top Computers, etc.)
Coordinate within Office Sign Off: __________ Date:
__________
3) Property Accountability has been satisfied (i.e.
assigned equipment returned,
O.S.S. office account card, etc.)
Coordinate within Office Sign Off: __________ Date:
__________
4) Information Resources Computer / Network ID's closed
out / terminated
Coordinate with Office of House Information Resources,
Office of Security, Rm. 650, FHOB, Ext. 66448 Sign Off:
__________ Date: __________
5) House / Congressional ID and keys have been returned
Coordinate with Office of Human Resources,
Office of Policy & Administration, Rm. 719, OHOB,
Ext. 52926 Sign Off: __________ Date: __________
6) Parking Permit returned
Coordinate with Office of Sergeant at Arms,
House Garage, Rm. G2-28, RHOB, Ext. 56749 Sign Off:
__________ Date: __________
7) Congressional Federal Credit Union has been advised of
forwarding address
(only applicable if you are currently a member)
Member Services, Subway Level, RHOB, Ext. 63100 (x603)
Sign Off: __________ Date: __________
CAO Check-Out Form
Page 2
8) Postal Operations notified of forwarding address
Coordinate with Office of Publications and Distribution,
Office of Postal Operations, Rm. B225, LHOB, Ext. 61492
Sign Off: __________ Date: __________
9) Travel Reimbursements have cleared
Coordinate with Office of Finance,
Office of Financial Counseling, Rm. 141, CHOB, Ext. 57512
Sign Off: __________ Date: __________
10) House Library reference materials returned and
account closed / terminated
Coordinate with House Library,
Rm. B18, CHOB, Ext. 50462 Sign Off: __________ Date:
__________
11) Library of Congress Reference materials returned and
account closed / terminated
Coordinate with Library of Congress,
Rm. LJ-G15, Jefferson Bldg., Ext. 75441 Sign Off:
__________ Date: __________
12) Financial Disclosure Termination Report has been
filed (SALARY REQUIREMENT
OF $83,160.00 and above)
Coordinate with Committee on Standards of Official
Conduct,
Suite HT-2, The Capitol, Ext. 57103 Sign Off: __________
Date: __________
13) Forwarding Address and Phone Number:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________________________
Separating employees who are indebted to the Federal
Government are subject to having collection action taken
against them to include withholding their final
compensation and/or any other payments due them such as
payment for unused annual leave.
I certify that all procedures required for separation
have been satisfied to the best of my knowledge and
belief:
___________________________________________
__________________
Employee Signature: Date:
___________________________________________
__________________
Supervisor's Signature: Date:
RETURN COMPLETED FORM TO THE HUMAN RESOURCES' OFFICE OF
POLICY AND ADMINISTRATION, ROOM 719, O'NEILL HOUSE OFFICE
BUILDING, WASHINGTON, DC, 20515-6610, (202) 225-2450.
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