Stipulation

SAMPLE EXHIBIT SHEET

Employee’s Claim for Benefits From Multiple Injury Trust Fund. 2/06

Employee's Claim for Benefits From Multiple Injury Trust Fund. 2/06

Designation of Service Agent

Application for Physicians Seeking Appointment as an Independent Medical Examiner

Form SF 50 Notification of Personnel Action

INSTRUCTIONS : NOTIFICATION OF PERSONNEL ACTION (Form SF 50)

A Standard Form 50, or SF50, is the form that provides a current or former federal employee with information regarding their work history with the government. The “Notification of Personnel Action” is a part of the federal worker’s complete employment record and includes information about promotions, appointments, pay increases, and separation.

In order to make a request for an SF 50, you must access the SF 50 form from your current or most recent department’s human resources division. In this case, we are reviewing the example of the SF 50 form used for the U.S. General Service Administration, obtained from their website.

Once you have the form, your employer must fill out section 1.

1. You must provide your identification information in boxes 1 to 4, including your name, social security number, date of birth, and effective date.

Next your department will identify what first and second actions you are requesting.

2. Boxes 5 and 6 will provide you with the nature of the action and the legal authority that has authorized the action.

If you are receiving a change of title, grade, promotion, or demotion, boxes 7 and 22 will be filled out.

3. Boxes 7 through 14 will describe your former position, the title, pay grades, and location of your position.

4. Boxes 15 to 22 will describe your new position obtained, the new title, applicable pay grades, as well as your new location.

Before completion, your SF 50 must provide additional information regarding your personal data that is related to your federal employment.

5. Veteran status, tenure, retirement plans, work schedules, and other personnel information will be provided.

Finally, your SF 50 will provide you with additional agency data and departmental information, if any, determined by the legal authority causing the action to take place.

6. Once your SF 50 is complete, you should review all information and keep a copy for your records, as you may need such information for future employment, pay, and qualification decisions made through federal employment.

ESA-1257A Final Notice of Referred Worker

INSTRUCTIONS: ARIZONA FINAL NOTICE TO EMPLOYER OF REFERRED WORKER (Form ESA-1257A)

Arizona employers may submit a form JBS-1028A if they wish to place public notice of a job opening through the state Department of Economic Security through its employer services division. A form ESA-1257A will be sent if it is determined by the federal government that a worker referred to this job is not qualified to work in the United States. This document can be found on the website maintained by the Arizona Department of Economic Security.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 1: In the first blank box, the applicable job order number will be entered.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 2: In the second blank box, the applicable employer number will be entered.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 3: In the third blank box, the applicable employer address will be entered.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 4: In the blank box in the next paragraph, the date on which you were initially referred a worker will be entered. The remainder of the paragraph explains the eligibility verification process.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 5: The next sentence states that the individual has now been found invalid to work in the United States.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 6: The next blank line will have the worker in question's name.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 7: The next blank line will have the date of the referral in question.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 8: In the next blank section, the name of the staff member completing this form will be entered.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 9: On the next blank line, the staff member will provide their signature.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 10: In the next blank section, the number of the employment service office will be entered.

Arizona Final Notice To Employer Of Referred Worker ESA-1257A Step 11: In the last blank section, the date of this notification will be entered. Further assistance in understanding this form can be obtained by calling the phone number at the bottom of the page.