TVA 3595 Veteran Status Information

TVA SENSITIVE INFORMATION

OMB No. 3316-0063

Exp. Date: MM/DD/YYYY

Veteran Status Information

Please TAB to gray areas

DO NOT WRITE IN THIS SPACE

Nonveteran Nondisabled Veteran Compensable Disabled Veteran      % Derivative Preference Veteran

Retired Veteran - No preference in reductions in-force Sole Survivor Veteran

Documentary evidence including dates of military, service reviewed; the status checked above determined.

Certified by:

     

Date

     

Instructions: Please complete this form in blue or black ink. Submit forms and appropriate documentation to Shared Resources Staffing and Recruiting, 1101 Market Street, EB 8B, Chattanooga, Tennessee 37402.

Part 1: Identifying Information

1.

Social Security Number

     

Date

     

2.

Last Name

     

First

     

Middle

     

Permanent Address:

3.

P.O. Box or Street No. and Street Name

     

4.

City

     

County

     

State

     

Zip Code

     

5.

Area Code/Telephone Number

     

6.

Type of work or position desired

     

7.

At which location would you accept employment?

     

8.

Have you previously worked for TVA? Yes No

If “Yes,” provide the dates worked and location:

     

Part 2: All preference claimants must complete Parts 1 and 2, sign Part 4 and provide with this application form DD214 and proof of campaign award, and/or current disability status.

9.

Name of veteran whose service preference is claimed

     

(type or print name exactly as it appears on discharge form):

10.

Is the veteran deceased? Yes No

11.

If deceased, give date of death

     

12.

Does the veteran have an existing disability recognized by the Veterans’ Administration as service-connected?

Yes No

If “Yes,” give claim number here and provide current evidence*

     

13.

Is the veteran receiving payment from the Veterans’ Administration due to a service-connected disability? Yes No

If “Yes,” provide current evidence.*

14.

Is the veteran receiving a pension or disability retirement benefits from the Veterans’ Administration or from a branch of the

Armed Forces? Yes No Give V.A. claim number here and provide evidence*

     

15.

Has veteran been awarded the Purple Heart for wounds/injuries received in action? Yes No

16.

Which are you? (check one) A. The veteran B. The veteran’s widow or widower**

C. The wife or husband of a disabled veteran** D. The mother of a deceased or disabled veteran**

17.

Was the veteran’s service in peace time only? Yes No

18.

If the answer to question 17 is “Yes,” was campaign or expeditionary medal authorized? Yes No

Name of campaign:

     

19.

Branch of Service

     

20.

Date of entry (or entries) into Armed Forces

     

21.

Date of separation (or separations) from service

     

22.

Rank at time of separation(s)

     

23.

Serial Number

     

24.

Number of days of lost time (AW 107; A 86; AWOL)

     

25.

Were all separations under honorable conditions? Yes No If “No,” give details on separate sheet.

26.

Did you receive a Sole Survivorship Discharge (under 10 U.S.C. 1174(i)) from a period of active duty from the armed forces after August 29, 2008. Yes No Date discharged: ___________. Include supporting documentation with this form.

Part 3: Complete if Retired Military

27.

If applicant/employee is a retired member of the uniformed services, provide the following information:

Uniformed service from which retired

     

Rank at retirement

     

28.

Is retirement from the uniformed service based upon disability (1) resulting from injury or disease received in the line of duty as

a direct result of armed conflict, or (2) caused by an instrumentality of war and incurred in the line of duty during a period of war

(see III REDUCTION, Salary Policy, for definition of “period of war”)? Yes No

29.

Is retirement based on credit for at least twenty years of full-time active service (regardless of when performed but not including

periods of active duty for training)? Yes No

30.

Will you be eligible in the future to retire from an uniformed service? Yes No

Uniformed service from which you will retire

     

Approximate date of retirement eligibility

     

Part 4: All Preference Claimants must sign here

I certify that the statements made by me in answer to all questions on this form are true to the best of my knowledge and belief.

Signature

Date

     

Proof to support applicant’s claim for veteran’s preference must be submitted with this form prior to closing date of job.

* Except for claim based on award of Purple Heart, for disability preference you must present documentary evidence at the time application is made (generally, a letter from the Veteran Affairs Office dated within the last 12 months stating the percentage of disability).

** If you are claiming preference as the spouse of a veteran who has a service-connected disability, a veteran’s widow or widower who has not remarried, or as a widowed, divorced, or separated mother of a deceased or totally disabled veteran who was honorably discharged, please complete the appropriate part on page 2 of this form.

Derivative Preference Information

(Complete only if you are claiming veterans preference as spouse, widow/widower, or mother of veteran.)

Part 5: Spouse of Veteran with Service-Connected Disability
31.	Are you presently married to the veteran? Yes No
	(If “No,” you are ineligible for this preference and need not complete the questions below).
32.	Is the veteran currently working? Yes No If “No,” go to item 33.
33.	If currently working, what is the veteran’s present occupation?			     
34.	What was the veteran’s occupation, if any, before military service?				     
35.	What was the veteran’s military occupation at the time of separation?					     
36.	Has the veteran been employed, or is he/she now employed by the Federal civil service or DC Government? Yes No
	A. Title and grade of position most recently or currently held		     
	B. Name and Address of Agency	     
	C. Dates of employment: From	     					To		     
37.	Has the veteran resigned from, been disqualified for, or separated from a position in the Federal civil service or DC
	Government along the lines of his/her usual occupation because of service-connected disability? Yes No
	If “Yes,” submit documentation of the resignation, disqualification, or separation.
38.	Is the veteran receiving a civil service retirement pension? Yes No
	If “Yes,” give the Civil Service or Federal Employee retirement annuity number							     
Part 6: Widow/Widower of Veteran
39.	Were you married to the veteran listed in Part 2 when he/she died? Yes No
40.	Have you remarried? Yes No
41.	Did the veteran die while on active duty? Yes No
Part 7: Natural Mother of Deceased or Disabled Veteran
42.	Is the veteran your natural child? Yes No
	(Preference cannot be granted on the service of a stepchild, foster child, or adopted child.)
43.	Is the natural father of your child (check one):
	A. Living with you? B. Deceased? C. Divorced from you? D. Separated from you?
44.	Is the natural father of your child (or the husband of your remarriage) with whom you are now living totally and permanently
	disabled? Yes No
45.	If natural father or veteran is deceased or divorced from you, have you remarried? Yes No
46.	Are you widowed, divorced, or legally separated from the husband of your remarriage? Yes No
47.	If the veteran is deceased, did he/she lose his/her life under honorable conditions while on active duty either during a war,
	between April 28, 1952 and June 30, 1955, or in a campaign or expedition for which a campaign medal has been authorized?
	Yes No (If “Yes,” submit death certificate from armed forces.)
48.	If the veteran is still living, was he or she separated with an honorable or a general discharge? Yes No
49.	Is the veteran permanently and totally disabled? Yes No If “Yes,” provide documentation of disability.
Burden Estimate Statement (Pursuant to 5 CFR 1320.21) Public reporting burden for this collection of information is estimated to average 15 minutes 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this burden, to Agency Clearance Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, TN 37402; and to the Office of Management and Budget, Paperwork Reduction Project (3316-0063), Washington, DC 20503.

Privacy Act Statement

Subsection (e) (3) of 5 U.S.C.  522a (Section 3 of the Privacy Act) requires that TVA inform you of its authority to request information and the uses which TVA may make of the information requested. That subsection further requires TVA to inform you of the effects of not providing any or all of the requested information.

TVA’s authority to request the information you will provide is derived from the TVA Act and the Veterans Preference Act of 1944, as amended, and will be used to determine your preference eligibility status. Information provided on the form may be furnished to people, agencies, organizations, or institutions in order to verify such status.

Furnishing the requested information is voluntary; however, failure to provide all or part of the information and documentation requested may result in a lack of further consideration for employment, your preference status not being considered, or in the termination of your employment.

Information provided on this form is normally used only to determine eligibility for veterans preference. Information obtained on this form may be furnished to third parties as authorized by law. For example, should a dispute arise or a congressional inquiry be made regarding TVA employment practices, the information may be made available outside of TVA in the course of that dispute or inquiry. Further, information on this form may be made available to law enforcement agencies in the exercise of their duties, or to a prospective employer or TVA contractor upon proper request.

Distribution: Original - ESC

TVA 3595 [04-10-2013] Page 9 of 9

TVA SENSITIVE INFORMATION