Free Printing I:\SF\SF3100~1\SF_3100.FRP - Federal

Last Name

First Name

Middle Name

Date of Birth MM DD YYYY

Soc. Sec. No.

Agency

Payroll Office

Location

Payroll Office No.

1. 2. 3. 4.
(RECORD EACH NAME CHANGE-STRIKE OUT PREVIOUS NAME)

Service History Effective Date (1) Action (2) Base Pay (3) Remarks (4) Year (5) Calendar Year Salary Deductions (6)

Fiscal Record Accumulated Salary Deductions (7) Remarks (8)

Register of Separations Number (SF 3103)

U.S. Office of Personnel Management 5 CFR 841

NSN 7540-01-247-0006 3100-102

Individual Retirement Record (Federal Employees' Retirement System)

PRINT

SAVE

CLEAR

Standard Form 3100 Revised January 1987