Form DOE F 3220.5 DOE F 3220.5 APPLICATION FOR CONTRACTOR COMPENSATION APPROVAL

DOE F 3220.5 (8/86)

PREVIOUSLY AD-37 (All other editions

are obsolete)

_{1. Contractor and Location}

U. S. DEPARTMENT OF ENERGY

APPLICATION FOR CONTRACTOR COMPENSATION APPROVAL

(Use Attachment To Provide Explanations, Supporting Data, and Justification)

_{2. Contractor Number}

OMB Control No.

1910-0600

PROPOSED SALARY ACTION

_{3. Employee’s Name 6.}

_{4. Title 5. Grade}

New Hire

Merit Increase

Promotion

_Transfer

_{Other (specify)}

7. Proposed Date

8. Proposed Base Salary

9. Annual Increase 10. Period since last increase

11. Annualized

_Increase

_{12. Optional}

Most recent performance evaluation

^ANNUAL

^MONTHLY _$

^RATING

^DATE

_{% months %}

_{13. Proposed}

_Incentive

14. Salary Range - Minimum -

15. Estimate the percent of employee salary that will be charged to the contract

16. Salary Increase Fund

Compensation $

Maximum -

% %

17. Base salary data of others in same salary range

_{or comparable positions}

18. Is incentive compensation or bonus allowable

_{under the contract?}

22. Remarks:

Highest Salary Average Salary Lowest Salary

Number of employees in the range

YES NO

If yes, complete the following for the past 3 years: Amount of bonus Date received:

19. Compa-Ratio or

Range Percentile

_{20. Person to whom this individual reports:}

_{21. Other direct compensation e.g., location allowance}

_{Title Type}

Salary $

Amount $ or %

a. College or university and location	b. No. yrs. attended	c. Major field	d. Degree/Date

23. EDUCATION

a. Effective date –Present	b. Position Title	c. Base Salary	d. Employer and Location

24. SALARY HISTORY (Report salary history for past 5 years)

_{25. APPROVALS AND CONCURRENCES}

25a. Contractor:

Signature: Title:

Date:

25b. Headquarters

MA26: Signature: Date: Program Official:

Title:

_{Signature: Date:}

25c. Contracting officer (or designee)

Signature: Title:

Date:

_{26. DOE APPROVED SALARY 27. DOE APPROVED EFFECTIVE DATE}

OMB Burden Disclosure Statement: Public reporting burden for this collection of information is estimated to average 137 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of Information, Records and Resource Management, SO-31, U.S. Department of Energy, Paperwork Reduction Project (1910-0600), Washington, DC 20585, and to the Office of Management and Budget, Paperwork Reduction Project (1910-0600),Washington,DC20503.

PRIVACY ACT STATEMENT, Information about an individual called for on this form and which pertains to the individual’s rights benefits and privileges may become part of a “System of Records” subject to the Privacy Act of 1974. That Act provides that information be collected directly from the individual to the greatest extent practicable, and that such records pertaining to him are subject to his access upon request.

The purpose of the information is to provide the basis for DOE review and approval of contractor employee’s compensation for reimbursement at the specified level under the contract.

If information is inadequate or incomplete, action on the request may be delayed or withheld. Authority: Department of Energy Organization Act, P.L. 95-91.