OMB Number 1105-00 Renewal of Incentive Part 3

OMB Number 1105-0086. Expires xx/xx/xxxx

Part 3: Renewal Request - Component Review

(Part 3 must be completed and validated by a component / office (or equivalent) HR
representative.)

A. Attorney Information
1 Attorney's Name
2
3
4

Component / Office
(for AUSAs, include district)

Attorney's grade (including step) (if

applicable)
Attorney's annual gross salary as of
December 31, 2009 (use 2009 base pay -

do not include locality pay)

GS

Step

or N/A

$

5 Has the attorney been the subject of any

performance or disciplinary actions in the past
12 months? (If yes, then specify. Attach
information as needed).

6. Has the attorney engaged in

substantiated misconduct in the past 12
months? (if yes, then specify. Attach
information as needed).

B. Attorney's Position Information
1
2

3

What is the attorney's current position?
Was the attorney in a leave without pay
status or in any other non-pay status in
2009?
If the answer in B 2 is "yes," was the
absence due to uniformed service or
compensable injury?

YES
NO
YES

(Ensure copy of orders or other
documentation is attached. No extension
of service obligation completion date is
required.)

NO
List dates of absences below, then correct

component records to extend the existing
service obligation completion date by the
total amount of time spent in non-pay
status.

4
5
6
7

Is the Renewal Request Complete?
For a checklist, visit the ASLRP link at
http://www.usdoj.gov/oarm/aslrp/checklist.pdf

Name of Component HR Representative
Signature of Component HR
Representative
Work Phone

YES
NO

Return to requester for corrective action.

E-Mail

If complete, please forward to the component Executive Officer (or equivalent) (or
delegate) for further processing.