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END OF SERVICE FORM - NOT TO BE USED FOR RETIREES PART - I To be completed by the department LAST NAME FIRST NAME MAILING ADDRESS INIT. / SOCIAL SECURITY STREET CITY STATE ZIP CODE DEPARTMENT NAME ACTION FORM COMPLETED BY DATE COMPLETED F*A. S* NO. EFFECTIVE DATE Resignation Death Termination Other please specify TITLE POSITION NO. LAST DAY WORKED please attach resignation letter SIGNATURE OF CHAIRPERSON OR HEAD OF OFFICE DATE OF SIGNATURE PART - II To be completed by the Personnel Office of Human Resource Services Number of days accumulated or compensatory time for which lump sum payment is to be made Entitled to summer pay of one month two months Verified by 20151 Seq. No* i forms eosfrm01. doc 8/01 R06 R19 last day worked last day on payroll R22 Ending date remuneration. / SOCIAL SECURITY STREET CITY STATE ZIP CODE DEPARTMENT NAME ACTION FORM COMPLETED BY DATE COMPLETED F*A. S* NO. EFFECTIVE DATE Resignation Death Termination Other please specify TITLE POSITION NO. LAST DAY WORKED please attach resignation letter SIGNATURE OF CHAIRPERSON OR HEAD OF OFFICE DATE OF SIGNATURE PART - II To be completed by the Personnel Office of Human Resource Services Number of days accumulated or compensatory time for which lump sum payment is to be made Entitled to summer pay of one month two months Verified by 20151 Seq. S* NO. EFFECTIVE DATE Resignation Death Termination Other please specify TITLE POSITION NO. LAST DAY WORKED please attach resignation letter SIGNATURE OF CHAIRPERSON OR HEAD OF OFFICE DATE OF SIGNATURE PART - II To be completed by the Personnel Office of Human Resource Services Number of days accumulated or compensatory time for which lump sum payment is to be made Entitled to summer pay of one month two months Verified by 20151 Seq. No* i forms eosfrm01. doc 8/01 R06 R19 last day worked last day on payroll R22 Ending date remuneration. / SOCIAL SECURITY STREET CITY STATE ZIP CODE DEPARTMENT NAME ACTION FORM COMPLETED BY DATE COMPLETED F*A. S* NO. EFFECTIVE DATE Resignation Death Termination Other please specify TITLE POSITION NO. LAST DAY WORKED please attach resignation letter SIGNATURE OF CHAIRPERSON OR HEAD OF OFFICE DATE OF SIGNATURE PART - II To be completed by the Personnel Office of Human Resource Services Number of days accumulated or compensatory time for which lump sum payment is to be made Entitled to summer pay of one month two months Verified by 20151 Seq. No* i forms eosfrm01. doc 8/01 R06 R19 last day worked last day on payroll R22 Ending date remuneration.

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