Employee Labor and Relations Manual - NALC Br. …

1 Forms IndexIndexELM Contents1053 ELM , July 20, 2006 Forms Index FormNumber Form Title ELM ReferenceCFC 100 CFC Pledge 214 Certificate of Release or Discharge From Active Employee s Notice of Traumatic Injury and Claimfor Continuation of , , , , , , , , , , , , , , , of Occupational Disease and Claim , , , , , , , , , of Federal Employee s Recurrence of Disabilityand Claim for , , , , of Termination of Disability and/or for Compensation by Widow, Widower, , , , , for Compensation by Parents, Brothers, Sisters,Grandparents, or , , , Superior s Report of Employee s , , for , , for Examination and/or , , , , , , , Status , Physician s , 931 Request for Wage Separation , , , , , , 934 Request for Information or Reconsideration of , , , 936 Request for Verification of UCFE Wage and SeparationInformation Furnished on Form ES , , for Death Benefits (Federal Employees Group Life Insurance Program)

2 , , , DEPS tatement of for Accidental of Living , FormW-4 PWithholding Certificate for Pension or Annuity 1431 Spouse s Consent to Survivor 1482 Agency Certification of Status of Reemployed , IndexIndexELM Contents1054 ELM , July 20, 2006 ELM Reference Form Title FormNumberOPM 1528 Notification of Earnings for Medicare 2 Citation and Notification of , 300 Log of Work-Related Injuuries and , , , , , , , , , , 300 ASummary of Injuries and , , , , , , , 301 Injury and Illness Incident , , , 50 Notification of Personnel , , , , , , , , , , , , , , , , , , , , 202 Health Benefits Refund Payment 337 Clearance Record for Separated 820 Ranking of Position , , 231PS 991 Application for Promotion or , 999 Application for Reinstatement , , 1012 Travel , , 1017-ATime Disallowance 1164 Claim for Reimbursement for Expenditures on , , 1188 Cancellation of Organization Dues from , , , Exhibit Savings Bond Authorization for Purchase andRequest for 1216 Employee s Current Mailing , 1221 Advanced Sick Leave 1223-AEarnings , , 1223-BEarnings Statement Net to , , 1224 Court Duty Leave Statement of 1314 Regular Rural Carrier Time 1555 Statement of Account for CAGs H 1723 Assignment 1727 Award , 1767 Report of Hazard, Unsafe Condition, or , , , , , , , , , IndexIndexELM Contents1055 ELM , July 20, 2006 ELM Reference Form Title FormNumberPS 1769 Accident , , , , , , , , , 1772 Accident 1773 Report of Hazard 1782 Training Request and.

3 1783On-the-Job Safety 1902 Justification for Billing Accounts , , 1961 Employee Uniform Allowance , , 2146 Employee s Claim for Personal 2240 Pay, Leave, or Other Hours Adjustment , , 2246 Terminal Leave 2248 Monetary Payroll , 2342 Request: Unemployment Compensation 2411 Check List for Pre-Retirement 2417 Confidential Statement of Employment and FinancialInterests (for Use by Postal Service Employees) 2432 Individual Training Progress , 2485 Medical Examination and 2488 Authorization for Medical , 2489 Identification of Physical/Mental 2491 Medical Report First Aid 2548 Individual Training , 2556 Third Party Statement of , , , Exhibit 2557 Employee s Third-Party Recovery , , , ,Exhibit , Exhibit 2559 Third Party Claim Information , , Exhibit 2560 Referral of Third Party , , Exhibit 2562 Injury Compensation Program Notice of Potential ThirdParty , , , , , Exhibit 2573 Request OWCP Claim 2577 Assignment of Claim to the , , ,Exhibit IndexIndexELM Contents1056 ELM , July 20, 2006 ELM Reference Form Title FormNumberPS 3074 Request for Waiver of Claim for Erroneous Payment , , 3111 Specific Notice to Employees Entering (or Already in)

4 Nonpay Status - Change in Health Benefits 3189 Request for Temporary Schedule Change for , 3239 Payroll Deduction Authorization to Liquidate PostalService , , , , , , , , , Exhibit , , Exhibit 3241 Statement of Receipts and Disbursements (EmployeeSocial and Recreational Funds) , Exhibit 3544 Post Office Receipt for 3971 Request for or Notification of , , , , , , , , , , , , , , , , , , , , , 3972 Absence , 3973 Military Leave 4584 Observation of Driving 4943 Locker 5900 Hiring , 6375 Uniform Allowance Stop Payment 6803 Wage and Separation , , , , , , 6886 Thrift Savings Plan Request for , , , 7314 Medical 7380 MDC Supply 7381 Requisition for Supplies, Services, or , 8006 Uniform Allowance Code Sheet (For Regular, Contract, or Work Clothes Program) , , 8201 Pre-Tax Health Insurance Premium Waiver/RestorationForm for Career 8202 Pre-Tax Health Insurance Premium Election/Waiver Formfor Noncareer 8214 Certificate of OSHA, Safety, and Environmental IndexIndexELM Contents1057 ELM , July 20, 2006 ELM Reference Form Title FormNumberRI 76-10 Assignment of Federal Employees Group Life , 8 Notice to Federal Employees About , , 180 Requests Pertaining to Military RecordsExhibit 278 Financial Disclosure Report for Executive 813 Verification of a Military Retiree s Service in NonwartimeCampaigns or , Exhibit 1150 Record of Leave , 1152 Designation of Beneficiary Unpaid Compensation ofDeceased Civilian 1153 Claim for Unpaid Compensation of Deceased , 1187 Request for Payroll Deductions for Labor , , , , , , , , 2800 Application for Death.

5 2801 Application for Immediate , 2801-1 Certified Summary of Federal 2802 Application for Refund of Retirement , , 2803 Application to Make Deposit or 2804 Application to Make Voluntary 2806 Individual Retirement 2809 Employee Health Benefits Election , , , , , , , , , , , , , , , , , , , , , , , , , , , ,Exhibit , Exhibit 2810 Notice of Change in Health Benefits , , , , , , , , , , , , , , , , , , , ,Exhibit , Exhibit 2811 Transmittal and Summary Report to 2817 Life Insurance Election (FEGLI) , , , , , , , , , , , , , , , , , , , , , , IndexIndexELM Contents1058 ELM , July 20, 2006 ELM Reference Form Title FormNumberSF 2818 Continuation of Life Insurance Coverage as a Retiree , , 2819 Notice of Conversion Privilege Federal Employees Group Life Insurance , , , 2821 Agency Certification of Insurance , , , , , , , 2822 Request for Insurance (FEGLI)

6 , , 2823 Designation of , , , , , , , , 3102 Designation of Beneficiary Federal Employees Retirement 3104 Application for Death , 3106 Application for Refund of Retirement 3107 Application for Immediate 3107-2 Spouse s Consent to Survivor 3108 Application to Make Service Credit Savings Plan Election , , , of of Address for Separated to Spousal Relating to Deceased of Information Between Savings Plan Loan , , Loan Transfer for Full In-Service Withdrawal Hardship In-Service Withdrawal