Form 12854 GOVERNMENT SERVICE INFORMATION

Form 12854
(November 2015)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-1919

Government Service Information

1. Name

2. DOB

3. SSN

4. Other name(s) used in former employment (if different)

5. Have you previously worked or are you currently working for the Federal Government (including the U.S. Postal Service)?
Yes (if yes, list all Federal Employment, including appointments with the U.S. Postal Service in the table below)
No (if no, proceed to 6 below)
Name of Agency

Location

Dates(s) of Employment From/To

Important Note to Federal Retirees, including U.S. Postal Service Retirees:
If you are receiving a Federal pension, also referred to as an annuity, you may continue to receive payments while employed at the
Internal Revenue Service (IRS); however, your salary must be reduced by the amount of the annuity, dollar-for-dollar.
6. Check applicable box, sign and date where indicated
I have read the above statement and understand that the salary I earn while employed by the IRS will be reduced by the amount
of my federal pension (annuity), dollar-for-dollar. I also understand that I am responsible for repayment of any monies not properly
deducted from my salary as required by law.
I am not receiving a Federal pension (annuity). I understand the above is not applicable to me, although my signature is required.
Applicant signature

Date

Probationary Period Statement
Applicants who are selected from an external (Delegated Examining) announcement 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 (in part), "The first
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, unless upon reinstatement a probationary period has already been completed. 5
CFR 315.802 states (in part), "Prior Federal civilian service counts towards completion of probation when it is: 1) in the same agency; 2)
in the same line of work; and, 3) contains or is followed by no more than a single break in service that does not exceed 30 calendar
days.”
Applicant signature

Date

Privacy Act Statement
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.
Privacy and Paperwork Reduction Act.
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.) Your response is voluntary. We ask for the information on this form to carry out the mission of the Internal Revenue Service. We need the information to process your application for
employment with the Internal Revenue Service. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control
number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue Department of the Treasury —
Internal Revenue Service law. Generally, tax returns and return information are confidential, as required by code 6103. The time needed to complete this form will vary depending upon the individual
circumstances. The estimated average time to complete this form is 15 minutes. If you have 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.

Catalog Number 30776H

www.irs.gov

Form 12854 (Rev. 11-2015)