Fillable COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS DIVISION OF

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COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS DIVISION OF

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CHANGE OF DUTY STATION
SEPARATION FROM W ORK
OUTSTANDING CLEARED
DEPARTMENT/ ACTIVITY HEAD(S) DATE
DIR. OF REVENUE CYCLE DATE
DIR. OF FINANCIAL SERVICES DATE
DIR. OF REVENUE AND TAX DATE
MANAGER, UTILITY BRANCH DATE
HOUSING OFFICER DATE
MEDICAL REFERRAL OFFICER DATE
SCHOLARSHIP ADMINISTRATOR DATE
CUSTOMS OFFICIAL DATE
_______________
DATE
TEL: (670) 322-1201 / 1202 / 1203
COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS
DEPARTMENT OF FINANCE
DIVISION OF FINANCIAL SERVICES
DATE CLEARANCE IS PREPARED: _______________________________________________
This Clearance Sheet is being processed to clear the employee from any outstanding financial obligation owing to the CNMI Government.
OBLIGATIONS
EMPLOYEE DATA REASON FOR CLEARING
NAME OF EMPLOYEE: __________________________________________________________
STATUS OF EMPLOYEE: ________________________________________________________
PLACE OF EMPLOYMENT: ______________________________________________________
CHANGE OF HOUSING STATUS
(GOVERNMENT TO PRIVATE)
EFFECTIVE DATE OF SEPARATION: ______________________________________________
In the event the employee has an obligation to the government, he/she must obtain a signature from each of the officials listed below, to clear the
employee from any of the outstanding obligation. Upon receipt of the completed Clearance Sheet, the Payroll Section, within the Department of Finance
will process and issue the employee's last payroll check.
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
STATUS
________________________________________
________________________________________
________________________________________
________________________________________
7. MEDICAL REFERRAL
8. SCHOLARSHIP OFFICE
9. DIVISION OF CUSTOMS SERVICES
1. ______________________________________
3. ADVANCE TRAVEL, ANNUAL/SICK LEAVE
4. PENALTIES/TAXES
5. POWER, SEWER, AND WATER
2. MEDICAL/DENTAL CARE
6. HOUSING/ ALLOWANCES
CERTIFYING OFFICIALS
REMARKS
SIGNATURE OF EMPLOYEE FORWARDING ADDRESS
EMPLOYEE CLEARANCE SHEET (04/19/2021)
SIGNATURE
______________________________________
_______________________________________________
_______________________________________________
_______________________________________________
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COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS DIVISION OF

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Completed 15 February 2022

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