13022 Returned Request Form

OMB No. 3095-0037 Expires xx/xx/xxxx
RETURNED REQUEST FORM
YOUR REQUEST IS RETURNED WITHOUT ACTION FOR THE REASON(S) CHECKED BELOW. IF YOU RESUBMIT YOUR REQUEST, PLEASE RETURN ALL ATTACHED PAPERS, INCLUDING THIS FORM.
Further information is needed before we can locate the record needed to process your request. Please complete the items marked below.
			SOCIAL SECURITY NUMBER	     			DATE OF BIRTH		     
			INFORMATION FOR EACH PERIOD OF EMPLOYMENT (IF necessary, continue below or on a separate page)
	NAMES USED DURING FEDERAL SERVICE				EMPLOYING AGENCY AND LOCATIONS				DATES OF EMPLOYMENT
	     				     				     
	     				     				     
	     				     				     
	The request must include the authorization/handwritten signature of the person who is the subject of the record.
	If you are requesting information on a deceased individual, please submit proof of death.
	Please state exactly what information or documents you need.
	We are unable to locate the requested record based on the information you have provided. Please check the information contained in your request. If you can furnish any corrected information or any additional information to verify the claimed service, please resubmit your request.
	A request from a Federal agency for the transfer of a personnel record must be submitted on Standard Form 127, Request for Official Personnel Folder, or an authorized equivalent. Please submit your request on SF 127, in duplicate.
	Please submit a separate Standard Form 127 for each individual record being requested.
	Please complete the return address block on all copies of Standard Form 127.
	The return address must clearly state the name of the Federal Agency with which your office is affiliated. Please enter the agency name and resubmit your request.
	Standard Form 127 may not be used to request information or copies of documents. Please resubmit your request on agency letterhead.
	Standard Form 127 may not be used to request the transfer of medical records. Please submit Standard Form 184, Request for Employee Medical Folder, in duplicate.
	The request form you submitted is only for the use of Federal agencies. Please resubmit your request in letter form.
	The agency named in your request does not retire personnel records to this Center. Please submit your request directly to that agency.
	The record needed to respond to your request has not been received at this Center. Please submit your request to the last or current employing agency.
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION Authority for collection of the information is 44 U.S.C. 2907 and 3103 and Public Law 104-134 (April 26, 1996) as amended in title 31, section 7701. Disclosure of the information is voluntary. The principal purpose of the information is to assist the National Personnel Records Center in locating and verifying the correctness of the requested records or information to answer your inquiry. Routine uses of the information as established and published in accordance with 5 U.S.C. 522A (E) (4) (D) include the transfer of relevant information to appropriate federal, state, local, or foreign agencies for use in civil, criminal, or regulatory investigations or prosecution. In addition this form will be filed with the appropriate military or civilian records and may be transferred along with the record to another agency in accordance with the routine uses established by the agency which maintains the record. If the requested information is not provided, it may not be possible to service your inquiry. PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT An agency may not conduct or sponsor a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 3095-0037. The information requested on this form is being collected and used by the National Personnel Records Center to identify and locate civilian personnel records that could not be identified and located in response to the original inquiry. Public burden reporting for this collection of information is estimated to be five minutes per response , including time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE ADDRESS SHOWN BELOW.
                       								Date:       ____________________________________ For the Chief, NATIONAL PERSONNEL RECORDS CENTER (Civilian Personnel Records) 111 Winnebago Street St. Louis MO 63118-4199

NATIONAL ARCHIVES AND RECORDS ADMINSTRATION NA FORM 13022 (REV. 12-05)