List of Experts and Consultants Hired Under 5 U.S.C. 3109 Employing Agency Code: Who Served During Calendar Year: Contact Name: Phone: ( ) Department or Agency: Date: M.I. Type (E or C) Schd (I or O) Days Worked $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Last Name First Name Dollars Paid Form authorized for local reproduction American LegalNet, Inc. www.FormsWorkFlow.com OPM Form 1623 Revised May 2008 Instructions for Completing "List of Experts and Consultants Hired under 5 U.S.C. 3109" This annual report to OPM is required by 5 U.S.C. 3109(e) from all agencies that used and paid employees hired under section 3109 during the year reported. Each agency submits, by February 28, one consolidated report covering the entire agency for the year ending December 31. Send the report to: Expert and Consultant Reports, Center for Talent and Capacity Policy, U.S. Office of Personnel Management, 1900 E Street, NW, Room 6500, Washington, DC 20415. A computer-prepared report in the same format is acceptable. A negative reply is not required. You may duplicate copies of the report form for further use. Notes: Do not report employees who were (1) not paid, or (2) hired under any other appointment authority. Do not report services procured by contracts. Complete the following report items: Employee agency code. Enter first 2 letters of the "Agency/subelement" code, found in OPM's The Guide to Personnel Data Standards , Appendix 1. Who served during calendar year xxxx. Enter 4 digits of the year reported. Contact name and phone. Enter name and phone number of the agency person who can Contact name and phone. Enter name and phone number of the agency person who can provide more information about this report. Department or agency. Enter department or agency name. Date. Enter date the report is submitted. The format is MM/DD/YYYY. Last name, first name, M.I. Enter full name and middle initial of expert or consultant. Type. Enter "E" for expert or "C" for consultant to show position in which employed. Schd. Enter "I" for intermittent or "O" for other than intermittent, to show work schedule. Days. Enter number of days the employee worked as an expert or consultant for your agency during the year reported. Dollars paid. Enter total gross pay your agency gave the employee for expert or consultant work during the year reported. Use the "wages" figure, box 10, on the IRS W-2 Statement, unless the employee also worked in some other capacity for your agency during the year. OPM Form 1623 Revised May 2008 American LegalNet, Inc. www.FormsWorkFlow.com Page 2