Form CD-126 U.S. Department of Commerce
(REV. 4-08 )
DAO 202-299
SEPARATION CLEARANCE CERTIFICATE
Section I. To be completed by IMMEDIATE SUPERVISOR
1. Initiate this form 1 (one) week prior to the employee’s separation date, according to Departmental and bureau instructions.
2. Complete Section I of this form.
3. Advise the employee of his/her responsibility regarding the clearance process and give the form to the employee.
4. Upon the employee’s receipt of all clearance signatures AND his/her completion of Section III, you must complete Section
IV of this form and hand carry to the Servicing HR Office.
NAME OF SEPARATING EMPLOYEE
SEPARATION DATE
DATE CD-126 INITIATED
FULL NAME OF ORGANIZATION
TYPE OF SEPARATION
Leaving Federal Service Transfer to Another Agency Reassignment within Commerce
REQUEST FOR PERSONNEL ACTION, SF-52 Submitted Attached Not Required
INTERIM SUMMARY PERFORMANCE APPRAISAL, CD-430 (APS/APMS employees)
CD-541 (APS/APMS employees)
Attached Not Required
Required when employee is reassigned to another position in the Department or transfers to another Federal agency
after serving in his/her position for 120 days or more during the appraisal cycle (90 days or more for SES).
LEAVE AUDIT, CD-527
LUMP SUM LEAVE PAYMENT, CD-529
Attached Not Required
Attached Not Required
Section II. Clearance Required fo