Form Ad 349 – Fill Out and Use This PDF

FORM AD-349

U.S. DEPARTMENT OF AGRICULTURE

AGENCY USE

(REV. 12/93)

EMPLOYEE ADDRESS

ACTION

AGENCY

EFFECTIVE

CODE

DATE

SECTION I

Complete Section I with your current or new residence mailing address. This address is used to

mail out employee Pay and TSP statements, W-2 forms and other personal documents.

NOTE: This form does not change the U.S. Savings Bond address.

1. NAME (LAST, FIRST, MIDDLE)

2. SOCIAL SECURITY NO.

3. STREET ADDRESS OR P.O. BOX

4. APT NO.

5. CITY NAME

6. STATE or COUNTRY NAME

7. ZIP CODE

AGENCY USE

CITY CODE

COUNTY CODE

STATE OR COUNTRY CODE

SECTION II

FOR EMPLOYEES WITH DIRECT DEPOSIT COMPLETE BLOCKS 13 AND 14 ONLY.

Employees who wish to receive their checks in the mail complete blocks 8 through 14 with

your current or new check mailing address.

8. STREET ADDRESS or P.O. BOX

9. APT NO.

10. CITY NAME

11. STATE or COUNTRY NAME

12. ZIP CODE

AGENCY USE

CITY CODE

COUNTY CODE

STATE OR COUNTRY CODE

13. SIGNATURE OF EMPLOYEE

14. DATE SIGNED

This form was electronically produced by National Production Services Staff

PRIVACY ACT NOTICE FOR AD-349, EMPLOYEE ADDRESS

General

This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals completing Form AD-349.

Authority

5 USC 301.

Purpose and Uses

This form is used to obtain an employees home address and check mailing address.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b) (Privacy Act of 1974)

Disclosure by you of your Social Security Number (SSN) is mandatory to obtain the services, benefits, or processes that you are seeking. Solicitation of the SSN by the United States Department of Agriculture is authorized under provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. It will be used primarily to identify your records that you file with the U.S. Department of Agriculture. The SSN also will be used by the U.S. Department of Agriculture and other Federal agencies in connection with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants who have identical names and birth dates, and whose identifies can only be distinguished by the SSN.