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 for All Employees Instructions for Employees: 1. Follow your supervisor’s instructions and your organizations clearance procedures as soon as you receive this form from your supervisor. 2. To avoid delay in your final paycheck, this form must be completed and submitted to your servicing HR Office before your final paycheck, lump sum leave or any other monies due you can be released. You MUST clear each office/function that has been determined by your supervisor. 3. Upon receipt of all signatures return this form to your supervisor. 4. Your supervisor will complete Section IV of the form and submit to the Servicing HR Office. Instructions for Clearance Officials: 1. Indicate clearance of chargeable items by printing in and signing the applicable block with your full name, date and phone number. 2. Note the reason any chargeable item was not accounted for or returned and if appropriate, indicate the dollar value of the unaccounted items to be collected from the employee. 3. Follow bureau/office clearance procedures to ensure designated authorizing official(s) has cleared. of Page OFFICE/FUNCTION CLEARED BY: (Printed Name and Signature) DATE PHONE Name: 1. SECURITY a. CD-43 or other official identification ---------------------------------- b. Door Keys and/or Electronic Door Key Cards ---------------------------------- c. Investigative Credential and Badge ---------------------------------- d. Security Debriefing/Courier Authorization, CD-75 ---------------------------------- 2. INFORMATION TECHNOLOGY ACCESS a. Financial – CBS, CRS ---------------------------------- b. HRIT – NFC, HRDS, EPIC, LMS, ACS, Hiring Management ---------------------------------- c. Administrative – Phone listing, e-mail account ---------------------------------- d. Phone Card ---------------------------------- 3. PERSONAL PROPERTY a. Property Custodian ---------------------------------- b. Property Accountibility Officer ---------------------------------- c. Bureau Property Management Office ---------------------------------- 4. FINANCE a. Travel Advance ---------------------------------- b. Imprest Fund (where applicable) ---------------------------------- 5. ACQUISITION MANAGEMENT a. Purchase Card ---------------------------------- 6. ADMINISTRATIVE SERVICES a. Metro Subsidy ---------------------------------- b. Library ---------------------------------- c. Passports ---------------------------------- d. Parking ---------------------------------- of Page OFFICE/FUNCTION CLEARED BY: (Printed Name and Signature) DATE PHONE 7. EMPLOYEE’S IMMEDIATE OFFICE a. Travel Card (Employee is not delinquent on their Government issued travel card) ---------------------------------- b. Continued Service Agreements (i.e. Student Loan Repayment, Recruitment Bonus, etc) ---------------------------------- c. Timekeeper Certification – T&A coded final ---------------------------------- d. T&A Access terminated ---------------------------------- 8. HUMAN RESOURCES a. Receipt of Lump Sum leave form ---------------------------------- b. Receipt of Leave Audit form ---------------------------------- SECTION III. EMPLOYEE CERTIFICATION I certify that, except as otherwise indicated, I have no Government property, records or documents, including classified material issued or furnished by the Department of Commerce or reproduced by me, and I am not otherwise indebted to the United States Government. I certify that I have reviewed all the non-record documents (defined in Department Administrative Order (DAO) 205-3) that I plan to remove from the Department. None of these documents contain national security information or other information afforded protection under various statutes or regulations, such as privacy act information or trade secrets; related to any pending or contemplated civil, criminal, or administrative proceeding or other program activity where their release could prejudice the matter, if removed, would hinder the efficient continued functioning of an office or my successor; if removed, would diminish the records or other documentary information needed for the official business of the Department; if removed, would violate the confidentiality of any interest protected by law, such as national security, privacy, trade secrets; if removed, would exceed normal administrative economies (i.e., impose an unreasonable cost or burden created by copying or removing the materials from the building); or if removed, would unnecessarily expose, or risk exposing, to the public any internal deliberations, opinions, legal or policy advise, law enforcement materials, or other professional work-product of any office or employee of the Department. In addition, I understand that I must obtain clearance from the appropriate official possessing authority under Section 4 of DAO 205-12 before I will be permitted to remove any documents that would not normally be released to a third party under the Freedom of Information Act. SIGNATURE DATE SECTION IV. SUPERVISOR CERTIFICATION The supervisor's failure to comply with the requirements of CD-126, Separation Clearance Certificate and/or the policies as stated in DAO 202-299, Clearance of Employee Accountability, may result in disciplinary action. Employee has not cleared as indicated above and I have not certified the employee's time and attendance record. (Note: Supervisor must notify the HR Servicing HR office to initiate debt collection). SIGNATURE (Print Name and Sign) DATE SECTION V. SERVICING HR OFFICE (Check appropriate response) I acknowledged receipt of the CD-126. This form was was not completed in its entirety. Action will be taken to collect the debt. SIGNATURE (Print Name and Sign) DATE of Page Name: I certify that the employee has personally cleared each office as indicated in Section II of this form as well as any other office identified in the supplemental clearance procedures.