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.
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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:

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_______________________________________________________

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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.