Doe F 3220.5 U. S. Department Of Energy Application For Contractor Co

U. S. DEPARTMENT OF ENERGY

DOE F 3220.5
(8/86)

OMB Control No.
1910-0600

APPLICATION FOR CONTRACTOR COMPENSATION APPROVAL

PREVIOUSLY AD-37
(All other editions
are obsolete)

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

1. Contractor and Location

2. Contractor Number

PROPOSED SALARY ACTION
3. Employee’s Name

6.
New Hire

4. Title

Merit Increase

Promotion

5. Grade

7. Proposed Date

9. Annual Increase

8. Proposed Base Salary
ANNUAL

MONTHLY

Transfer
10. Period since
last increase

$

Other (specify)
11. Annualized
12. Optional
Most recent performance evaluation
Increase
RATING
DATE

%
months
%
13. Proposed
14. Salary Range 15. Estimate the percent of employee salary
16. Salary Increase Fund
Incentive
Minimum that will be charged to the contract
Compensation $
Maximum %
%
17. Base salary data of others in same salary range
18. Is incentive compensation or bonus allowable
22. Remarks:
or comparable positions
under the contract?
YES
NO
Highest Salary
Number of
If yes, complete the following for the past 3 years:
employees in
Average Salary
Amount of bonus
Date received:
the range
Lowest Salary
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

%

23. EDUCATION
a. College or university and location

b. No. yrs. attended

c. Major field

d. Degree/Date

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

b. Position Title

c. Base Salary

d. Employer and Location

–Present

25. APPROVALS AND CONCURRENCES
25a. Contractor:

25b. Headquarters

Signature:

MA26: Signature:
Program Official:

Title:

Title:

Date:

Signature:

26. DOE APPROVED SALARY

25c. Contracting officer (or designee)
Date:
Signature:
Title:
Date:

Date:

27. DOE APPROVED EFFECTIVE DATE

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.