Forms

FORM

EXPLANATION

AO75a

Type of Appointment Checklist - Law Clerk

Law Clerk appointments of less than four years are considered term appointments and are not eligible for coverage under the Federal Employees Retirement System.

Law Clerks are generally not covered under the Judicial Leave Act unless the appointing officer has indicated otherwise.

Please sign and date the form where indicated. Do not mark any of the boxes on the form.

AO75b

Type of Appointment Checklist - Staff Attorney

Staff Attorney appointments of less than four years are considered term appointments and are not eligible for coverage under the Federal Employees Retirement System.

Staff Attorneys are covered under the Judicial Leave Act.

Please sign and date the form where indicated.

AO78

Application for Judicial Branch Federal Employment

Please complete the Application as completely as possible making sure to include any prior federal work experience. If you do not know where you will be residing while employed with the court, please leave the address line blank and we will insert the address and room number for the office where you will be employed. Incomplete data could affect the appointment grade or delay the processing of the appointment, thus delaying receipt of your first salary check.

AO78a

United States Courts Appointment - Oath of Office

Do not write anything on Section A or on Section C of the AO78a; these portions are completed by the Human Resources Department upon receipt of your completed forms. On Section B you should print your name, as you want it to appear on payroll, just above the Oath of Office. The Oath of Office should be taken and signed in the presence of a notary public or your appointing officer.

Background Investigation Form

Background Required Information Form

All employees and volunteers in federal courts must undergo mandatory background checks. Please complete this form where indicated.

EEO Reporting Form

U.S. Court of Appeals - EEO Reporting Form
Self-Identification Form - Race/Ethnic, Gender and Disability

ELMO

ELMO Signature Form

Please sign this form where indicated, keeping your signature within the allotted area

Emergency Contact Form

Emergency contact form: confidential and strictly for emergency purposes only.

Federal Employees Dental and Vision Insurance Program
(FEDVIP)

Please visit the FEDVIP website at www.opm.gov/insure/DentalVision/index.asp for more information and enrollment instructions.

FMS 2231

Fast Start Direct Deposit Form

All employees are required to have their salary check sent directly to a financial institution by electronic fund transfer. The Fast Start Direct Deposit Form must be submitted to the Human Resources Department by the end of your first pay period.

I-9

Employment Eligibility Verification

A list of acceptable documents used to establish identity and employment eligibility is listed on the second page of the form. Instructions for completing the form are attached as well. Only fill out the top portion (part 1). Be prepared to produce the documents used to establish identity within the first three days of your employment. The bottom portion (Part 2) will be completed by this office.

SF 1152

Designation of Beneficiary [Unpaid Compensation of Deceased Civilian Employee]

An page of examplesof designations is included on the second page of the form. A duplicate copy of the form and instructions for completing the form are attached as well.

SF 2809

SF 2809
[If you experience difficulty in opening this form, right click on the link and 'Save Target As' to save a copy to your computer rather than trying to open it directly in your browser.].

Federal Employees Health Benefits Election Form This form is due 60 days from your entrance on duty. Please see the Health Insurance area of this web site for links to more detailed health benefits information.

SF 2809 Form Instructions
Using the comparison chart booklet and individual plan booklets, select the health plan and option that best fits your health insurance needs. You have 60 days from the first day of employment to elect health insurance coverage. If choosing an HMO, you must select a Primary Care Physician and indicate that selection on the bottom of your enrollment form. You must be on the payroll for at least one day before you are eligible for health insurance. Your health insurance will become effective the first Monday of the following pay period in which this office receives your completed registration form. If you decline coverage at this time or wish to change coverage at a later date, you must wait until the next open season enrollment held in November of each year. Changes made during this period become effective the beginning of the first full pay period of the coming year.

SF 2817

Life Insurance Election Form
This form is due 31 days from your entrance on duty. Please see the Life Insurance
area of this web site for links to more detailed life insurance benefits information.
Federal Employee Group Life Insurance (FEGLI) Basic Coverage is term insurance with 1/3 of the cost paid for by the Federal Government. All eligible employees are automatically enrolled in the Basic Coverage from the date of entrance on duty unless coverage is waived as indicated in the general instructions. You have up to 31 days from your first day of employment to elect or waive basic coverage or choose further options. If you do not want life insurance coverage you must complete the form and sign the waiver. If the form with signed waiver is received in the Human Resources Department within the first pay period of your employment any deductions that may be taken from your first paycheck will be refunded to you.

TSP 1

Thrift Savings Plan Election Form

You are eligible to begin regular employee payroll deductions, on a pre-tax basis, at any time during your employment. Each pay period we will deduct your contributions to the TSP from your pay check in the amount you choose. We will continue to do so until you make a new TSP election changing the amount of your contribution or stopping it.

In order to begin, change, or stop your employee contribution, you must make a TSP contribution election on Form TSP-1. This form is available from Human Resources or directly from the TSP web site.

Please see the Retirement area of this web site for links to more detailed TSP information.

W-4
federal

Federal Employee's Withholding Certificate Form

Self Explanatory

W - 4
state

• IL	IL Dept. of Revenue Withholding Tax Form

• IN	IN Dept. of Revenue Withholding Tax Form

• MO	MO Dept. of Revenue Withholding Tax Form

• WI	WI Dept. of Revenue Withholding Tax Form