EFTA00036380.pdf

U.S. DEPARTMENT OF JUSTICE Employee Locator Information
INSTRUCTIONS: This form is to be completed by all employees upon initial employment (accession) and whenever any information on the form changes. Changes should be promptly recorded by submission of this form to your personnel office. In accordance with the provisions of the Privacy Act of 1974, submission of some data is MANDATORY, other data is requested on a VOLUNTARY basis for the safety and convenience of the employee. The MANDATORY or VOLUNTARY nature of the data is indicated in the applicable Privacy Act Statement. Certain portions of the form are to be completed by the employee's personnel office or administrative officer. Employees should leave these portions of the form blank. If you have any questions regarding completion of the form, please consult your personnel office.

EMPLOYEE IDENTIFICATION
PRIVACY ACT STATEMENT: SOCIAL SECURITY NUMBER-1: AUTHORITY: Executive Order 9397 dated November 22, 1943. 2. PURPOSE AND USE: The Social Security Number (SSN) is used as a unique identifier for matching locator records to records in personnel and payroll files. Use of the SSN ensures correct identification of records for employees with the same name. 3. EFFECTS OF NON-DISCLOSURE: Disclosure of the SSN is MANDATORY. Failure to disclose the SSN on accession will result in your payroll check not being processed. Failure to disclose the SSN while reporting changes will result in the changes not being effected.

L1
TO BE COMPLETED BY PERSONNEL OFFICE
2. CONTROL NUMBER
3. TYPE OF ACTION
[ ] 1 Original [X] 2 Change
4. NAME (Last, First, Middle Initial)
NOEL, JONA A
5. SOCIAL SECURITY
[Redacted]
6. SUBMISSION DATE
10.25.18

CURRENT RESIDENCE ADDRESS FOR TAX PURPOSES
PRIVACY ACT STATEMENT: RESIDENCE ADDRESS-1. AUTHORITY: 5 U.S.C. Section 5516, 5517 and 5520; 26 U.S.C. Sections 6001 and 6109. 2. PURPOSE AND USE: To meet the reporting requirements of Federal, State and Local tax withholding programs. 3. EFFECTS OF NON-DISCLOSURE: Disclosure of current Residence Address is MANDATORY. Failure to disclose the current Residence Address on accession will result in violation of the cited authorities and possible penalties as prescribed therein.

7. STREET ADDRESS (No., Name, St., Dr., Pl., etc.)
[Redacted]
8. SECOND LINE STREET ADDRESS (if necessary)
Bronx
9. CITY
Bronx
10. COUNTY OR FOREIGN COUNTRY
[Blank]
11. STATE
NY
12. ZIP CODE
[Redacted]

CURRENT RESIDENCE ADDRESS AND TELEPHONE NUMBER
PRIVACY ACT STATEMENT: RESIDENCE ADDRESS AND TELEPHONE NUMBER-1. AUTHORITY: 5 U.S.C. Section 301. 2. PURPOSE AND USE: To contact employees at their residence on matters of an official nature relating to their employment with the Department of Justice. Access to this information is limited to the employee's supervisor(s) OR individuals authorized by the supervisor(s). 3. EFFECTS OF NON-DISCLOSURE: Submission of this data is VOLUNTARY. If the data is not submitted, supervisory personnel may have difficulty locating employees to inform them of emergency work situations.

TELEPHONE NUMBER
[Redacted]
15. EXTENSION (if any)
[Blank]
TO BE COMPLETED BY PERSONNEL OFFICE
16. LOCATION CODE OF RESIDENCE
[Blank]
17. MAY THE CURRENT RESIDENCE AND TELEPHONE NUMBER BE USED TO CONTACT YOU ON MATTERS RELATING TO YOUR EMPLOYMENT WITH THE DEPARTMENT OF JUSTICE? [X] YES [ ] NO

WASHINGTON, DC METROPOLITAN AREA EMPLOYEES ONLY-COMMUTER CLUB (CAR POOL) INFORMATION
[Standard Privacy Act Statement text regarding Commuter Club]
18. WASHINGTON, DC METROPOLITAN AREA EMPLOYEES ONLY
(If you are not interested in the Commuter Club, skip this question).
[ ] Y Yes, I wish to join the Commuter Club
[ ] N Remove my name and personal information from the Commuter Club
[ ] R Report request - I am a Commuter Club member and want an updated carpool report listing

EMERGENCY LOCATOR INFORMATION
PRIVACY ACT STATEMENT: EMERGENCY LOCATOR-1. AUTHORITY: 5 U.S.C. Sections 301 and 7901. 2. PURPOSE AND USE: To obtain emergency treatment or to notify friends or family in the event of employee injury or illness. 3. EFFECTS OF NON-DISCLOSURE: Submission of this data is VOLUNTARY and solely for the employee's safety and convenience.

L2 PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY
20. NAME
[Redacted]
29. RELATIONSHIP
Significant Other
22. CITY
Bronx
23. STATE OR COUNTY
NY
TELEPHONE NUMBER
[Redacted]

L3 PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY
28. NAME
[Blank]
29. STREET ADDRESS
[Blank]
30. CITY
[Blank]
31. STATE OR COUNTY
[Blank]
TELEPHONE NUMBER
[Blank]

OFFICE ADDRESS (Completed by Administrative Officer)
36. ORGANIZATION NAME
[Blank]
37. BUILDING NAME (if any)
[Blank]
38. ROOM NUMBER
[Blank]
39. STREET ADDRESS
[Blank]
40. CITY
[Blank]
41. COUNTY OR FOREIGN COUNTRY
[Blank]
42. STATE
[Blank]
43. ZIP CODE
[Blank]

L4
TELEPHONE NUMBER
48. AREA CODE
FTS [ ] YES [ ] NO
(IF NON FTS, LIST AREA CODE)
47. SEVEN DIGIT NUMBER
[Blank]
48. EXTENSION (if any)
[Blank]
PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY
82. BUILDING CODE
[Blank]
15. EXTENSION (if any)
[Blank]

FORM DOJ-233 JUN 84
EFTA00036380