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: Executive Order 9697 dated November 22, 1943.
2. PURPOSE AND USE: The Social Security Number (SSN) is used as a unique identifier for matching locator records to records in personnel and payroll files. Use of the SSN ensures correct identification of records for employees with the same name.
3. EFFECTS OF NON-DISCLOSURE: Disclosure of the SSN is MANDATORY. Failure to disclose the SSN on occasion will result in your payroll check not been processed. Failure to disclose the SSN while reporting changes will result in the changes not being effected.

L1:
TO BE COMPLETED BY PERSONNEL OFFICE: <empty>
2. CONTROL NUMBER: <empty>
3. TYPE OF ACTION:
[ ] 1 Original
[ ] 2 Change

4. NAME (Last, First, Middle Initial): Noel Tova A

5. SOCIAL SECURITY: <empty>

6. SUBMISSION DATE: 9.25.18

## CURRENT RESIDENCE ADDRESS FOR TAX PURPOSES

PRIVACY ACT STATEMENT: RESIDENCE ADDRESS-1. AUTHORITY: 5 U.S.C. Sections 5519, 5517 and 5820; 26 U.S.C. Sections 6301 and 8108.
2. PURPOSE AND USE: To meet the reporting requirements of Federal, State and Local tax withholding programs.
3. EFFECTS OF NON-DISCLOSURE: Disclosure of current Residence Address is MANDATORY. Failure to disclose the current Residence Address on occasion will result in violation of the cited authorities and possible penalties as prescribed therein.

7. STREET ADDRESS (No., Name, St., Dr., Pl., etc.):<empty>

8. SECOND LINE STREET ADDRESS (if necessary): Bronx

9. CITY: Bronx

10. COUNTY OR FOREIGN COUNTRY: NY

11. STATE: NY

12. ZIP CODE:<empty>

## CURRENT RESIDENCE ADDRESS AND TELEPHONE NUMBER

PRIVACY ACT STATEMENT: RESIDENCE ADDRESS AND TELEPHONE NUMBER-1. AUTHORITY: 5 U.S.C. Section 501. 2. PURPOSE AND USE: To contact employees at their residence on matters of an official nature relating to their employment with the Department of Justice. Access to this information is limited to the employee's supervisor(s) OR individuals authorized by the supervisor(s). 3. EFFECTS OF NON-DISCLOSURE: Submission of this data is VOLUNTARY. If the data is not submitted, supervisory personnel may have difficulty locating employees to inform them of emergency work situations.
TELEPHONE NUMBER: <empty>
16. EXTENSION (If any): <empty>
TO BE COMPLETED BY PERSONNEL OFFICE: <empty>
18. LOCATION CODE OF RESIDENCE: <empty>
17. MAY THE CURRENT RESIDENCE AND TELEPHONE NUMBER BE USED TO CONTACT YOU ON MATTERS RELATING TO YOUR EMPLOYMENT WITH THE DEPARTMENT OF
[x] 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 enroll Department of Justice employees in the Commuter Club. The Commuter Club is sponsored and operated by the Metropolitan Washington Board of Trade. Information necessary to Commuter Club Membership is supplied on a VOLUNTARY basis by each employee. 2. PURPOSE AND USE: To supply employees with a list of persons who live in close proximity to them for car pooling purposes. VOLUNTARY joining the Commuter Club will result in the employee's name, home address, employer (agency), office address, office telephone number and approximate working hours (Form DOJ-233 Employee Locator Items 4, 7, 8, 9, 10, 11, 12, 38, 39, 42, 43, 44, 47, and 48) being sent to the Commuter Club's automated data processing system. The Commuter Club will supply employee name, employer (agency), and office telephone number (Form DOJ-233 Employee Locator Items 4, 38, 47, and 48). 3. EFFECTS OF NON-DISCLOSURE: Disclosure of this information is VOLUNTARY. Failure to disclose will result in employee not becoming a member of the Commuter Club and, therefore, no employee information will be sent to the Club.

18. WASHINGTON, DC METROPOLITAN AREA EMPLOYEES ONLY
(If you are not interested in the Commuter Club, skip this question).
Y
N
R
[ ] Yes, -I wish to join the Commuter Club
[ ] Remove my name and personal information from the Commuter Club
[ ] Report request - I am a Commuter Club member and want an updated carpool report listing

## EMERGENCY LOCATOR INFORMATION

PRIVACY ACT STATEMENT: EMERGENCY LOCATOR- 1. AUTHORITY: 6 U.S.C. Sections 301 and 7001. 2. PURPOSE AND USE: To obtain emergency treatment or to notify friends or family in the event of employee injury or illness. 3. EFFECTS OF NON-DISCLOSURE: submission of (his data is VOLUNTARY and solely for the employee's safety and convenience.
L2 PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY: <empty>
L3 PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY: <empty>
20. RELATIONSHIP: Significant Other
28.: <empty>
29.: <empty>
22. CITY: Bronx
23. STATE OR COUNTY: NY
30. CITY: Bronx
31. STATE OR COUNTY: NY
TELEPHONE NUMBER: <empty>
32. AREA CODE: <empty>
33. SCREEN NAME/ADDRESS: <empty>
27. EXT. 9 (if any): <empty>
TELEPHONE NUMBER: <empty>
34. AREA CODE: <empty>
35. SEVEN DIGIT NUMBER: <empty>
36. ROOM NUMBER: <empty>
OFFICE ADDRESS (Completed by Administrative Officer)
36. ORGANIZATION NAME: <empty>
37. BUILDING NAME (If any): <empty>
38. STREET ADDRESS: <empty>
40. CITY: <empty>
41. COUNTY OR FOREIGN COUNTRY: <empty>
42. STATE: <empty>
43. ZIP CODE: <empty>
L4 TELEPHONE NUMBER: <empty>
49. AREA CODE: <empty>
[ ] FTS
[ ] YES
[ ] NO
IF NON FTS, LIST AREA CODE: <empty>
47. SEVEN DIGIT NUMBER: <empty>
48. EXTENSION(s) (If any): <empty>
PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY: <empty>
62. BUILDING CODE: <empty>
16. EXTENSION(s) (If any): <empty>

FORM DOJ-233 JUN 84

EFTA00036697