Form 12311 Repayment of a Federal Government Buyout and Possible Su

Form 12311 - Repayment of a Federal Government Buyout and Possible Suspension of Severance Pay

f12311--2005

Form 12311 - Repayment of a Federal Government Buyout and Possible Suspension of Severance Pay

OMB: 1545-1920

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OMB No. 1545-1920

Repayment of a Federal Government Buyout
and Possible Suspension of Severance Pay
Public Law (PL) 103-226, PL 104-208, and PL 107-296 require an individual who received a buyout at the time of separation from the
Federal Government to repay the entire amount of the buyout (including all deductions for taxes) to their former agency, if they are
re-employed within 5 years following the effective date of separation on which the payment was based. This requirement applies to any
employment, of any length, in any entity of the Federal Government. PL 104-208 and 107-296 requires the repayment be made prior to
the employee's first day of employment. PL 103-226 allows for the repayment over an extended period of time.
Section 1 – Prior Government Work Experience
1. Have you ever worked for the Federal Government
Yes

No

If you answered Yes to question 1, continue to Section 2. If you answered No, proceed to Section 4
Section 2 – Buyouts and Severance Pay
2. Have you ever been through a Reduction-in-Force (RIF)
Yes

No

3. If you answered Yes to question 2, are you currently receiving severance pay
Yes

No

If you answered Yes to question 3, depending on the type of appointment which you are being hired, your severance pay may be
suspended while employed by the U.S. government. It will resume after separating from the appointment. (5 CFR 550.710. & 550.711)
4. Have you received a Buyout within the past 5 years from the Federal Government
Yes

No

5. If you answered Yes to question 4, please indicate under which Public Law you received the Buyout. You must also provide a
copy of your separation SF-50 (Notification of Personnel Action) which documents the Buyout.
PL 104-208 or PL 107-296: under these PL's you must repay the entire amount of the Buyout to your former agency
before you can enter on duty with the Internal Revenue Service;
PL 103-226: under this PL you must repay the entire amount of the Buyout to your former agency but can do
so over an extended period of time.
Other Buyout not mentioned above. You must also provide a copy of your separation SF-50 (Notification of Personnel
Action) that documents the Buyout. You understand the conditions set forth of re-employment in the Federal Government
that may require the repayment of the buyout you received.
Section 3 – Declination of Employment (Complete only if applicable)
I have received a Buyout from the Federal government within the past five years; therefore, I am declining consideration for
employment and understand that my application will be placed in the inactive file.
Section 4 – Certification and Signature
I certify that I have completed the above in good faith and have received a copy of this notice.
Printed name

Social Security Number

Signature

Date signed
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Under Executive Order 9397, Federal agencies were required to use the Social Security Number (SSN) as a means of identifying
individuals in personnel record systems. Solicitation of your SSN is thus authorized by this executive order and will be used to ensure
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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.
Form 12311 (Rev. 11-2005)

Catalog Number 28092G

www.irs.gov

Department of the Treasury - Internal Revenue Service


File Typeapplication/pdf
File TitleForm 12311 (Rev. 11-2005)
SubjectNotice Regarding Repayment of a Buyout and Information Regarding Suspension of Severance Pay
Authorsean/pas
File Modified2005-11-07
File Created2005-11-07

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