Form 12885 Supplement to OF-612, Optional Application for Federal E

OMB Number 1545-1918

Supplement to OF-612, Optional Application for Federal Employment
Use this form as a supplement to your OF-612, Optional Application for Federal Employment.
SSN

Name
Address
City

State, ZIP Code

For each job you are adding to supplement your original application, you must provide ALL of the following
information. In addition, if you have EVER worked as a civilian for the Federal government (regardless of
when) you must complete all blocks for EACH federal job you have held.
Name of Employer
Employer Address
Employer City, State, ZIP Code
Supervisor Name
Dates of Employment

Supervisor Phone

(

From (MM/YY):

)

To (MM/YY):

Hours Worked Per Week

Salary

Job Title

If Federal employment,
Series and Grade:

Description of Work

Name of Employer
Employer Address
Employer City, State, ZIP Code
Supervisor Name
Dates of Employment

Supervisor Phone

(

From (MM/YY):

)

To (MM/YY):

Hours Worked Per Week

Salary

Job Title

If Federal employment,
Series and Grade:

Description of Work

– OVER –
Form

12885 (Rev. 3-2005)

Catalog Number 30945K

Department of Treasury — Internal Revenue Service

Name of Employer
Employer Address
Employer City, State, ZIP Code
Supervisor Name
Dates of Employment

Supervisor Phone

(

From (MM/YY):

)

To (MM/YY):

Hours Worked Per Week

Salary

Job Title

If Federal employment,
Series and Grade:

Description of Work

Privacy Act and Paperwork Reduction Act Notices
The U.S. Office of Personnel Management and other Federal agencies rate applicants for Federal jobs under the authority of sections 1104, 1302, 3301, 3304,
3320, 3361,3393, and 3394 of Title 5 of the United States Code. We need the information requested in this form and in the associated vacancy announcements to
evaluate your qualifications. In order to keep your records in order, we request your social security number (SSN) under the authority of Public Law 104-134 (April
26, 1996). This law requires that any person doing business with the Federal government furnish an SSN or Tax Identification number. This is an amendment to
title 31, Section 7701. Failure to furnish the requested information may delay or prevent action on your application. We use your SSN to seek information about
you from employers, schools, banks and others who you know. We may use your SSN in studies and computer matching with other Government files. If you do
not give us your SSN or any other information requested, we cannot process your application. Also, incomplete address and zip codes will slow processing. We
may confirm information from your records with prospective non-federal employees concerning tenure of employment, civil service status, length of service, and
date and nature of action for separation as shown on personnel action from of specifically identified individuals.
We ask for the information on this form to carry out the mission of the Internal Revenue Service. Your response is voluntary. You are not required to provide the
information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to
a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns
and return information are confidential, as required by code 6103. The time needed to complete this form will vary depending on the individual circumstances. The
estimated average time to complete this form is 30 minutes. If you have comments concerning the accuracy of this estimate or suggestions for making this form
simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave. NW, Washington, DC 20224.

SIGNATURE, CERTIFICATION AND RELEASE OF INFORMATION:
(
YOU MUST SIGN THIS APPLICATION SUPPLEMENT. Read the following carefully before you sign:
A false statement on any part of your application or this supplement may be grounds for not hiring you or for firing you after you begin work. Also, you
may be punished by fine or imprisonment (U.S. Code, Title 18, Section 1001).
I understand that any information I give may be investigated as allowed by law or Presidential order;
I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies and
other individuals and organizations, to investigators, personnel staffing specialists and other authorized employees of the Federal Government.
I certify that, to the best of my knowledge and belief, all statements on my application and on this form are correct, complete and made in good
faith.

Signature (Sign in dark ink.)

Form

12885 (Rev. 3-2005)

Date signed

Department of Treasury — Internal Revenue Service