Form 12854 PRIOR GOVERNMENT SERVICE INFORMATION

OMB NO.1545-1919
TEST DATE:

PRIOR GOVERNMENT SERVICE INFORMATION

TITLE OF EXAM:

If previously employed by the Federal government, complete the following:
NAME:
Name in Former Employment (if different)
Date of Birth:
NAME OF AGENCY

Social Security Number:
LOCATION

DATES
FROM
TO

SUPERVISOR
(if known)

IMPORTANT NOTE TO FEDERAL RETIREES:
If you are receiving an annuity, you may continue to receive payments while employed at the Internal Revenue
Service. However, your salary will be reduced by the amount of the annuity.
FEDERAL ANNUITANTS — SIGN AND DATE WHERE INDICATED
I have read the above statement and understand that the salary I earn while employed by the Internal Revenue
Service will be reduced by the amount of my federal annuity, on a dollar for dollar basis.
Applicant Signature

Date

PROBATIONARY PERIOD STATEMENT
External applicants who are currently working for other agencies or with the IRS are required by 5 CFR 315.801
and 802 to serve another probationary period. 5 CFR 315.801 states "The 1st year of service of an employee who
is given a career or career-conditional appointment is probationary when the employee is appointed from a competitive list of eligibles or was reinstated." 5 CFR 315.802 states "Prior Federalcivilian service counts towards
completion of probation when it….is in the same agency…in the same line of work and contains or is followed by
no more than a single break in service that does not exceed 30 calendar days."

Applicant Signature

Date

Reference: Privacy Act of 1974 (Public Law 93-579)
The information requested on this form will be used to update personnel records. Your name and/or social security number is only
used as an identifier (authorized under Executive Order 9397, dated November 1943.)
You are not required to supply the information requested on this administrative form. If you furnish none of the information, any
required processing of this form will be suspended, and your personnel record will receive no further processing. If you furnish only
part of the information required, the processing of your personnel records will be attempted; however, it may be significantly
delayed. If the information withheld is found to be essential to processing your records properly, you will be informed, and no further
processing will occur unless you supply the missing information.
Form 12854 (03-2005) Catalog Number 30776H www.publish.no.irs.gov
Previously issued as ANSC Form 9-5637 (Rev. 9/99)

Department of the Treasury — Internal Revenue Service