FormFlow 1.00Payroll Action Request AD343Dept. of Agriculture Aug. 1982 -- v 1.0]Kn:)r?2--Use this form when requesting a correction in an employee's tax withdrawal, health benefits or any action on an employee's payroll information. SSN . \ -!\ - - -r -r --- X - -FIELD NAME: "Social Security No." -- Enter the Social Security Number of the employee.Nameame @. -, -, - OB -B -FIELD NAME: "Employee's Name" -- Enter last name, first name, middle initial.Action . 6 -6 - hL -L -FIELD NAME: "Nature of Action to be Taken" -- Enter a brief description of desired action to be taken.Explanation @. X -!X - n -n -FIELD NAME: "Explanation of Circumstances Which Require This Action" -- Enter explanation of circumstances which require this action.Acct_Data . -- --FIELD NAME: "Accounting Data to be Charged and/or Credited" -- Enter the accounting classification code(s) or management code(s) to be charged or credited with the adjustment. Attachments . - - a--FIELD NAME: "Attachments Supporting or Authorizing This Action" -- List each document attached.Cntct_Person . -"-!"- 8-8-FIELD NAME: "Person to be Contacted for Additional Information" -- Enter the last name, first name, middle initial of person to be contacted for additional information.CntctPhone @. :*-!":*---P*-P*-()   `)-`)-FIELD NAME: "Telephone (Area Code and Number)" -- Enter telephone number and area code of person to be contacted for additional information. Enter the digits only. Check whether phone number is FTS or Commercial.FromDate E/ +-!+-+-+-+-+-// &+-&+-FIELD NAME: "From Date" -- Enter inclusive "From" date of adjustment. Enter the date with slashes in the format of "mm/dd/yy". The slashes will convert automatically.P_P1 . ,-!,- G,-,-FIELD NAME: "P/P" -- Enter inclusive "From" pay period of adjustment.To_Date E/ --!-- ---- ----FIELD NAME: "To Date" -- Enter inclusive "To" date of adjustment. Enter the date with slashes in the format of "mm/dd/yy". The slashes will automatically appear.----//P_P2 . */-!*/- E@/-@/-FIELD NAME: "P/P" -- Enter inclusive "To" pay period of adjustment.Agency_Cd @. Prsnnl_Cd @. Acct_Cd @. Agncy_Name @. 2-2- N2-2-FIELD NAME: "Agency Name and Mailing Address" (line 1) -- Enter agency nameAgncy_Addrs . (3-3- P3-3-FIELD NAME: "Agency Name and Address" (line 2) -- Enter agency street address.Agncy_City . 4- 4- .4-4-FIELD NAME: "City" -- Enter the agency city.Agncy_St . 5-! 5- 5-5-FIELD NAME: "State" -- Enter the agency state. Use a two-character abbreviation. For example, AL = Alabama, DC = District of Columbia, etc.Agncy_Zip @. 8-! 8-7-7-8-8-- N7-7-FIELD NAME: "Zip Code" -- Enter agency zip code. Use 5 or 9 digit zip code.TA_Cntrct .  Mail_Addrs . G-@G- G-G-[Term_Yes]=1Term_Date E/ I-!@I-H-H-I-I-// H-H- H-H-FIELD NAME: "Terminated Date" -- If YES has been selected for employee termination, enter termination date. Enter the date with dashes in the format of "mm-dd-yy". The slashes will automatically appear. H-H-[Term_Yes]=1Gross_AmtCB. Exempt :!! : o-o- :: \:\:FIELD NAME: "FSLA - Exempt" -- Check the exempt box for employees NOT covered under the Fair Labor Standards Act. Press the space bar to enter an 'X' in this field.Non_Exempt :!$: :: ,:,: h:h:FIELD NAME: "FSLA - Non-Exempt" -- Check the non-exempt box for employees covered under the Fair Labor Standards Act. Press the space bar to enter an 'X' in this field.Full_Time  :!! : \:\:  : : r:r:FIELD NAME: "Type of Employment - Full Time" -- Check appropriate block for type of employment. Press the space bar to enter an 'X' in this field.Part_Time :!": :: :: ::FIELD NAME: "Type of Employment - Part Time" -- Check appropriate block for type of employment. Press the space bar to enter an 'X' in this field.Term_No :!!::: ::[Term_No]=0 :: :: ::FIELD NAME: "Terminated If Yes - No" -- If employee is currently employed by USDA, check NO box. Press the space bar to enter an 'X' in this field.Term_Yes R:!$R: J:J: h:h: `:`:FIELD NAME: "Terminated If Yes - Yes" -- Check YES box if employee has terminated USDA employment. If yes, enter termination date and check mailing address or designated agency number. Press the space bar to enter an 'X' in this field.Intermittent :!": :: :: (:(:FIELD NAME: "Type of Employment - Intermittent" -- Check appropriate block for type of employment. Press the space bar to enter an 'X' in this field.First_40 :!": :: ::FIELD NAME: "Type of Employment - 1st 40 Hours" -- Check appropriate block for type of employment. Press the space bar to enter an 'X' in this field. :: Forest_Srv :!": :: :: ::FIELD NAME: "Type of Employment - Forest Service Alternator" -- Check appropriate block for type of employment. Press the space bar to enter an 'X' in this field.Reemployed :!$: N:N: :: d:d:FIELD NAME: "Type of Employment - Reemployed Annuitant" -- Check appropriate block for type of employment. Press the space bar to enter an 'X' in this field.RETIRt @. #"EXPLAN2ion @. :: ::FIELD NAME: "Explanation of Circumstances Which Require This Action" -- Enter explanation of circumstances which require this action.dBASESwiss"Courier1Univers (WN)"Modern2RomanHelv"Univers Condensed"LinePrinter1CG TimesCG Times (WN)""""daHHGc$-cs( !1%BR7csJӔPy$V%:mXc1aPζV%m1  Agncy_Addrs *:gmd0X Explanation :?:13 EXPLANATION OF CIRCUMSTANCES WHICH REQUIRE THIS ACTION PH%:md0X  Gross_Amt |:(|:14 GROSS AMOUNT OF ADJUSTMENT   P7V%Wm@1X  RETIR &:x-&:x-7 RETIREMENT COVERAGE CODE /* FPAfgm1X :Z-:Z-1T};/W:0cNX /OG:gW:::F-%W::c:-8ȃ-^:OܚG-w?2 aOGOⰿGX /;/W:0V%W*0X   Term_Date 0:0:DATE TERMINATED PxV%7m1X  :-:-6 FSLA"<8m1X  Exempt 9"R<8b1X  Non_Exempt Py$V%=3mX|1X  :,숷-:숷-2. ADJUSTMENT PERIOD E(INCLUSIVE)EqmN``GHX  : n-:n- PAYROLL ACTION REQUEST  FPAfmX :/R-:R-SUBMITTING OFFICE SEQUENTIAL REQUEST NUMBERq%V*%V*eIOgml1X  :@T-:T-INSTRUCTIONS ON REVERSE OF AGENCY COPY PLEASE READ CAREFULLY*Pzglm1X   XAJPc X  J:gx-J:x-U.S. DEPARTMENT OF AGRICULTURE NATIONAL FINANCE CENTER P.O. BOX 60,000 NEW ORLEANS, LOUISIANA 70160x*zg1X   SSN 4:ꍷ-4:ꍷ-9 SOCIAL SECURITY NO. qzPm1X   Nameame :=Ž-:Ž-10 EMPLOYEE'S NAME E(Last, First, Middle Initial)E J*Pgm0X Action :$:11 NATURE OF ACTION TO BE TAKEN JP=3{} Fm|1X   :- :-FROMq@{}=3V% F|0X  t:t:TOq@P F:OAfm1X  FromDate :-:-DATE q@:O F{}Af1X  P_P1 :(::(:P/P q@{} FoAf&0X  To_Date *:*:DATE q@o FV%Af&0X   P_P2 ::P/P q@PAfV%]vm1X  $:h-$:h-4. FROMq@P]v!m(l1X  Agency_Cd :-:-AGENCY CODE q!]v(l1X  Prsnnl_Cd ,: t-,:t-PERSONNEL OFFICE IDENTIFIER ]vV%l0X   Acct_Cd p-p-ACCT. STATION CODEqPV%ζml1X   Agncy_Name zq-$X-zq-X-AGENCY NAME AND MAILING ADDRESS qPmWS  Agncy_City  r-D- r-D-CITY q@WS0X  Agncy_St r-r-STATE q@V%S0X  Agncy_Zip Ds-Ds-ZIP CODE qPV%xmS1X   TA_Cntrct s-&-s--5 EMPLOYEE'S T & A CONTRACT POINT qPWV%m@1X  Tt--Tt--8 TYPE EMPLOYMENTqPH%m*0X  Mail_Addrs t-6t-CHECK MAILING ADDRESS OR DESIGNATED AGENT NUMBER qPmW*0X zu-0zu-12 TERMINATED IF YESe?{mb1X Full_Time ;/W:0c~NX /OG~u-~gW:~u-:F-~%W:~u-c:-8ȃ-^:OܚG-w?2 ;/W:0Fm1X  Part_Time Lm+0X  Term_No 9RLb+0X  Term_Yes 9eR?{bb1X Intermittent 9FRb1X  First_40 e?{Wb0X Forest_Srv FW0X  Reemployed ' M4%X z-J-z-J-EXEMPTW'M4XX {--{--NON-EXEMPTW/c~[7X {-ޕ-{-ޕ-INTERMIT- TENT X {--{--PART- TIME/c~[ X V|-j-V|-j-FULL- TIMEW X |-.-|-.-1ST 40 HOURS|ebX &}-&}-FOREST SERVICE ALTERNATOR|RVX }-}-REEMPLOYED ANNUITANT YX  ~- ~-NO;L_X  4YCoYX ~-~-YES*F%8Bg0X  Acct_Data R%-5R%-15 ACCOUNTING DATA TO BE CHARGED AND/OR CREDITED J*KF% gC g 0X   6-6-19 APPROVALq*]dgh N 0X -.-AUTHORIZED OFFICIAL'S SIGNATURE AND TITLE J*:BF%g0X  Attachments >-9>-16 ATTACHMENTS SUPPORTING OR AUTHORIZING THIS ACTION J*xF%IgC 0X  Ѐ-BЀ-18 EMPLOYEE'S SIGNATURE AND DATE SIGNED E(If Required)E J*yg}0X Cntct_Person -:-17 PERSON TO BE CONTACTED FOR ADDITIONAL INFORMATION l܃R%q~0X   CntctPhone P-.P-TELEPHONE (EArea Code and Number)E e^F%Nh  0X ւ-ւ-DATE APPROVED qr&h  X @-@-FORM AD - 343 (REV. 8/92)qg-1f  0  --NFC*:/%Ogd0X  EXPLAN2ion  p7M$r-ppCMCap7Cd #%o*d5`rg1 ----3Tg1f#f1  --PROCESSING COPYQ;/W:0cNX /OG-gW:-:F-%W:Q;/W:0g1f  0  f-f-AGENCY COPYQ;/W:0cNX /OGf-gW:f-:F-%W:fQ;/W:0