Form Hud-58 - Clearance For Separation Of Employee - 2007

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Clearance for Separation

U.S. Department of Housing

and Urban Development

of Employee

Oﬃ ce of Human Resources

For Headquarters Use Only.

See page 2 for Administrative Clearances

Part I. Request for Clearance

(To be completed by Administrative Oﬃ cer or equivalent)

Instructions for Administrative Oﬃ cer or Equivalent:

Initiate this form 5 days prior to an employee's separation. Advise the separating employee on local procedures for the clearance process.

Ensure that the employee signs this form in Part II and that the form is forwarded to the Servicing Human Resources Oﬃ ce before the employee sepa-

rates.

1. Name of Employee

2. Social Security Number

3. Date of Separation (mm/dd/yyyy)

4. Organization

5. Forwarding Address

6. Type of Separation

7. Oﬃ ce Door Keys

Leaving Federal Service

Transferring to Another Agency

Returned

None Issued

8. Relocation Services Agreement

Completed

Not Completed

Not Applicable

Note: If an agreement is not completed and the employee is not transferring to another agency, funds must be recovered unless the employee has obtained a waiver by the

Assistant Secretary for Administration. If funds should be recovered, explain in Part III and indicate the dollar amount to be collected.

9. Leave Record (HUD-260) must be attached to this form.

Are there any discrepancies between PC-TARE and the NFC database?

Yes

Note: For unresolved discrepancies requiring a change to the NFC database, the Leave Correction Memorandum must also be attached.

10.

Completed Student Loan Repayment Service Agreement

Telephone Number

Date (mm/dd/yyyy)

Yes

if yes date completed

Signature of Administrative Oﬃ cer or Equivalent

Part II. Employee Certiﬁ cation

Instructions for Employees:

To avoid delays in ﬁ nal salary payments, this form must be completed and returned to your Administrative Oﬃ cer or equivalent before you separate.

You must clear every item applicable to you and then sign the employee certiﬁ cation below.

If you want your ﬁ nal salary payments sent to an address other than where your salary payments are currently being sent, complete and attach an AD-

349, Declaration Sheet, to this form.

Employee Certiﬁ cation: I certify that I have no Government property, computer software/hardware, keys, records or oﬃ cial documents, including classi-

ﬁ ed material issued or furnished by the Department of Housing and Urban Development.

I understand that the depreciated value of Government property charged to me may be withheld from monies due me if the loss or theft of or damage

to such property is determined by a Board of Survey and the Reviewing Oﬃ cial to be due to negligence or intent on my part.

Date (mm/dd/yyyy)

As a HUD employee have you received any Student Loan Repayment Beneﬁ ts?

Yes

, if yes date completed _____________

NOTE: If yes, you completed a Service Agreement to remain in the service of the Department for a minimum period of three years

under the initial agreement and for 1 year for each calendar year that an additional beneﬁ t was issued. If you have not completed

the time under your Service Agreement, you are obligated to repay the Department the full amount of any Student Loan beneﬁ ts that

were paid.

Signature of Employee

Part III. Uncollected Indebtedness

Instructions for the Clearance Oﬃ cial: If any chargeable item listed in Part I or Part IV was not accounted for or returned, indicate the dollar value of the

unaccounted item to be collected from the employee's ﬁ nal salary payments.

Amount

Signature of Clearance Oﬃ cial

Item

$ $

Remarks

Amount

Signature of Clearance Oﬃ cial

Item

$ $

Remarks

Amount