CAO Sample PAF - DOTGOV.com

Employee Information

Name*

First Middle Last

Employee Number*

(Do not enter leading zeroes)

Social Security Number*

Employed by More Than One House Office?

Yes
No

Employing Office*

Office Type*

Member
Committee
Leadership
Officers / Other Legislative Offices

Position Number

Payroll Action

Type of Action*

Appointment
Title Change
Salary Adjustment
Salary Adjustment with Title Change
Termination
Leave Without Pay
Lump Sum Payment
Overtime Payment

Position Title*

Nonpermanent employees should be designated as Part-Time Employees, Paid Interns, Temporoary Employees, or Shared Employees and will automatically receive the respective designation as their position title.

Gross Annual Salary*

If employee is a civil service annuitant (includes U.S. House of Representatives), the gross annual salary shown should include the annuity received by the employee plus the salary received from the employing office.

Effective Date*

Supersedes Previous Action

Yes
No

Signature of Authorizing Official

Name of Authorizing Official

First Last

Title of Authorizing Official

If Member, please indicate state and district

Date

CAPTCHA

Payroll Authorization Form

Employee Information

Payroll Action

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