U.S. DEPARTMENT OF JUSTICE

Employee Locator Information

INSTRUCTIONS: This form is to be completed by ad employoes upon initial amplamant (assion) and whenever any information on the form changes. Change should be promptly recorded by sufrutation of this form to your personnal offica in accordance with the provisions of the Pthony Act of 1974, submission of some data is MANDATORY, other data is requested on a VOLUNTARY basis for the safety and convenience of the employee. The MANDATORY or VOLUNTARY nature of the data is indicated in the applicable Privacy Act Statement Certain portions of the form are to be comptated by the employoc's personnel office or administrative officer. Employoos should leave these portions of the form blank if you have any questions regarding completion of the form, please consult your personnel office

## EMPLOYEE IDENTIFICATION

PRIVACY ACT STATEMENT: SOCIAL SECURITY NUMBER-1: AUTHORITY: Eve Order 0397 dated November 22, 1943. 2 PURPOSE AND USE: The Social Security Number (SSN) is used as a unique Idoritor for matching locator records to records in personnel and payrol fa. Use of the SSN ensures correct identification of records for employoss with the same name 3. EFFECTS OF NON-DISCLOSURE Disclosure of the SSN I MANDATORY. Faure to disclose the SSN an accession will result in your payrod chack not been processed. Fabure to disclose the SSN who reporting changes will result in the not beinn affected

changes

TO BE COMPLETED BY PERSONNEL OFFICE

4. NAME (Last, First, Middle Initial

5. SOCIAL SECURITY

e. SUBMISSION DATE
10.26.18

L12.

CONTROL NUMBER

TYPE OF ACTION
1Origined 2 Change

Noel, Tova A

## CURRENT RESIDENCE ADDRESS FOR TAX PURPOSES

PRIVACY ACT STATEMENT: RESIDENCE ADDRESS-1. AUTHORITY: 5 USC Section 5518, 5817 and 5880, 28 USC Sections 6001 and 8109 2. PURPOSE AND USE: To meet the reporting requirements of Federal, State and Locd ex withholding programs. 3. EFFECTS OF NON-DISCLOSURE: Disclosure of at Residence Address la MANDATORY. Faure to disclose the current Residence Address on accession will sult in violation of the cited authorities and possible peraltes as prescribed herein

7. STREET ADDRESS (No., Name, St., Dr., Pl., etc.)

8. SECOND LINE STREET ADDRESS (if necessary)
Brony

9. CITY

Brony

Ny

10. COUNTY OR FOREIGN COUNTRY

11. STATE STATE

12. ZIP CODE

## CURRENT RESIDENCE ADDRESS AND TELEPHONE NUMBER

PRIVACY ACT STATEMENT: RESIDENCE ADDRESS AND TELEPHONE NUMBER-1. AUTHORITY: 6 US.C. Section 301. 2. PURPOSE AND USE: To contact employees at their residance on matters of an official nature relating to their employment with the Department of Justin. Accoss to this information is amited to the employed's supervisor(s) OR Individuals exhorted by the supervisors). 3. EFFECTS OF NON-DISCLOSURE: Submission of this data is VOLUNTARY. If the data to not submitted, supervisory personnal may have dintouty locating employees to inform them of emergency work situations.

TELEPHONE
NUMBER

15. EXTENSIONO any)

TO BE COMPLETED BY PERSONNEL OFFICE

16. LOCATION CODE OF RESIDENCE

17. MAY THE CURRENT RESIDENCE AND TELEPHONE NUMBER BE USED TO CONTACT YOU ON MATTERS RELATING TO YOUR EMPLOYMENT WITH THE

DEPARTMENT OF

YES

NO

## WASHINGTON, DC METROPOLITAN AREA EMPLOYEES ONLY-COMMUTER CLUB (CAR POOL) INFORMATION

PRIVACY ACT STATEMENT: 1. AUTHORITY: There is no statutory authority for the use of this information to enrol Department of Justice employees in the Commuter Chub. The Commuter Club is sponsored and operated by the Metropolitan Washington Board of Trade Information necessary to Commuter Chub Membership is supplied on a VOLUNTARY besis by each employee. 2. PURPOSE AND USE To supply employoos with a list of persons who ove in close prodity to them for car pooling purposes. VOLUNTARY Joining the Commuter Club will result in the employed's nama, home address, employor (agency), office address, office tolephone number and approdata working hours Form DO-233. Employee Lostor s 4,7,9, 10, 11, 12, 36, 37, 38, 40, 41, 42, 43, 47, and 48) being sent to the Commudar Chur's mated date processing system. The Commuter Club will supply employee nama, employer (agoncy, and office telephone number (Form DO1-233 Employee Locator tams 4, 38, 47, and 48) EFFECTS OF NON- DISCLOSURE: Dicture of this information to VOLUNTARY. Fature to disceso wil rosult in employee not becoming a member of the Commuter Club and theyutra, no employee Information will be sent to the Ch

## WASHINGTON, DC METROPOLITAN AREA EMPLOYEES ONLY-COMMUTER CLUB (CAR POOL) INFORMATION (cont.)

18. WASHINGTON, DC METROPOLITAN AREA EMPLOYEES ONLY

Y

Yes, wish to join the Commuter Club

(If you are not interested in the Commuter Club, skip this question).

NRemove my name and personal information from the Commuter Club

R Raport request-I am a Commuter Club member and want an updated carpool repart sting

## EMERGENCY LOCATOR INFORMATION

PRIVACY ACT STATEMENT: EMERGENCY LOCATOR-1. AUTHORITY: 6US.C. Sections 301 and 7001. 2. PURPOSE AND USE: To obtain emargancy treatment or to notify Monds or family in the event of amatoveo trary or Eness & EFFECTS OF NON-DISCLOSURE: submission of this data is VOLUNTARY and sokety for the amaloved's safety and convertonco

12 PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY

L3 PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY

20, RELATIONSHIP
Significant other

28

Bronx 23. STATE OR COUNTY STAFFER

30 CITY
Brom

| 31. STATE OR COUNTY STATE OR COUNTY

TELEPHONE
NUMBER

27. EXT.

TELEPHONE 32 AREA CODE las saevAIGHT MUURER

NUMBER

## OFFICE ADDRESS (Completed by Administrative Officer)

38, CRGANIZATION NAME

37. BUILDING NAME (if any)

38. ROOM NUMBER

39. STREET ADDRESS

40. CITY

41. COUNTY OR FOREIGN COUNTRY

42. STATE

43. ZIP CODE

TELEPHONE 48. AREA
NUMBER CODE FTS  YES  NO
OF NON FTS, LIST AREA CODE

47. SEVEN DIGIT NUMBER

LA

48. EXTENSION)

PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY

62. BUILDING CODE

15. EXTENSION any)

FORM DOJ-233 JUN 84

EFTA00037505