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 Action Base Pay Remarks Year Calendar Year Salary Deductions (6) Fiscal Record Accumulated Salary Deductions (7) Remarks (1) (2) (3) (4) (5) (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) American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 3100 Revised January 1987