Date Received in Office of Designated Agent Approved by OMB 3206-0229 APPLICATION FOR FEDERAL EMPLOYEE COMMERCIAL GARNISHMENT INSTRUCTIONS 1. Federal law, 5 U.S.C. § 5520a, provides for the commercial garnishment of the pay of Federal employees. 2. Each garnishment order or similar legal process in the nature of garnishment must be delivered to the agency's Designated Agent. (See 5 CFR Part 582 Appendix A and 5 CFR Part 581 Appendix A for the lists of Designated Agents to receive legal process.) 3. Employing agencies will generally begin to disburse amounts withheld from employee-obligor’s pay within 30 days of receipt by Designated Agent. 4. Employing agencies will not modify compensation schedules or pay disbursement cycles in responding to legal process. 5. 31 CFR Part 210 governs funds remitted by Electronic Funds Transfer. 6. See reverse side for Public Burden Statement. Title and Address of Employing Agency's Designated Agent Note: Service of legal process may be accomplished by certified or registered mail, return receipt requested, or by personal service only upon the agent to receive process as explained in 5 CFR 582.201, or if no agent has been designated, then upon the head of the employeeobligor's employing agency. A. EMPLOYEE IDENTIFICATION - 5 U.S.C. § 5520a requires sufficient information to enable the employing agency to identify the employeeobligor. Please provide as much of the information in items 1 through 5 as possible. 1. Full Name of Employee-Obligor 2. Date of Birth 3. Employee/Social Security Number 4. Employing Agency, Component, and Employee's Official Duty Station/Worksite Address and ZIP Code 5. Home Address or Current Mailing Address and ZIP Code 6. For Agency Use B. CASE INFORMATION 1. Name of Court and Case Number in Garnishment Order 2. Garnishment Amount 3. Legal process expiration date (if time limited) $ / 4. Is there a dollar amount or percentage limitation under the applicable law of the jurisdiction where the order has been issued that will result in a lower amount to be garnished than would otherwise be applicable under the Consumer Credit Protection Act, 15 U.S.C. § 1673? Yes No If Yes, provide a citation and a copy of the applicable provision:_____________________ / 5. Does the law of the jurisdiction where this legal process is issued have a "one order at a time" rule that precludes employers from garnishing more than one order at a time? Yes No 6. Does the law of the jurisdiction where this legal process is issued provide for the garnishment of interest amounts that are not reflected on the order or in item number B2? Yes No C. AUTHORIZED PAYEE IDENTIFICATION 2. Address of Authorized Payee, including ZIP Code / / / / 1. Full Name of Person Authorized to Receive Payment, as it appears on Court Order 3. Daytime Telephone - Area Code and Number 4. Signature of Authorized Payee, Creditor, or Creditor’s Representative, and Date Signed D. ELECTRONIC FUNDS TRANSFER (if available) 1. Name and Address of Authorized Payee's Financial Institution If you wish to request that the funds be remitted by electronic funds transfer rather than by paper check, please complete items D1 through D5. 2. Depositor (Payee) Account No. and Title Type of Account: / Checking / 3. 9-Digit Routing Transit No. of Authorized Payee's Financial Institution (Verify with Financial Institution) Savings 4. Name and Title of Authorized Payee’s Representative 5. Signature of Authorized Payee's Representative and Date Signed U. S. Office of Personnel Management Optional Form 311 (March 1997) American LegalNet, Inc. www.FormsWorkFlow.com Paperwork Reduction Act Statement on Public Burden This request for information is in accordance with the clearance requirements of 44 U.S.C. 3507. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, gathering the necessary data, and completing the form. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing the burden, to the U. S. Office of Personnel Management, OPM Forms Officer, Washington, DC 20415-7900. Regulations published by the Office of Management and Budget at 5 CFR 1320.8(b)(3)(vi) require the inclusion of a statement with each collection of information that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Optional Form 311 (back) American LegalNet, Inc. www.FormsWorkFlow.com