18. Immediate Supervisor (Name and Title)
U.S. Department of State
INTERGOVERNMENTAL PERSONNEL ACT AGREEMENT
INSTRUCTIONS
This agreement constitutes the written record of the obligations and responsibilities of the parties to a temporary assignment arranged under the
provisions of the Intergovernmental Personnel Act of 1970, 5 CFR 334 and 3 FAM 2416.
The term, State/Local Government or "Other" Organization, when appearing on this form, also refers to an institution of higher education, an
Indian tribal government, and any other eligible organization.
A copy of the completed and signed agreement should be retained by each signatory. The final agreement is filed on the left-hand side of the
employee's Official Personnel Folder (OPF).
Use the continuation sheet at page 5 when additional space is needed to respond to the question(s).
PART 1: NATURE OF THE ASSIGNMENT
Initial assignments, modifications, and all extensions require the approval of the Under Secretary for Management (M) or Designee.
1.
New Agreement Modification Extension
PART 2: INFORMATION ON PARTICIPATING EMPLOYEE
2. Name (Last, First, MI) 3. Last Four Digits of Social Security Number
4. Home Address (Street, City, State, Zip Code) 5a. Have you ever been on IPA assignment?
Yes No
5b. If yes, please provide the dates of each assignment (mm-dd-yyyy)
From To
From To
PART 3: PARTIES TO THE AGREEMENT
6. Identify U.S. Department of State (Office/Bureau which is party to the agreement) 7. Identify State/Local Government or "Other" Organization
8. Is assignment being made through a faculty fellows program?
Yes No
If yes, specify program below.
PART 4: POSITION DATA
A - POSITION CURRENTLY HELD
9. Employment Office Name and Address (Building, Street, City, State, ZIP) 10. Employee's Position Title
12. Immediate Supervisor (Name and Title)
11. Office Phone Number (Area Code)
B - TYPE OF CURRENT APPOINTMENT
Specify Type of Appointment
Excepted Service
Career or Career Conditional
Career Senior Executive Service
13. Federal Employee (Check Appropriate Box)
Indicate GS/GM/SES Grade, Level
and Step and Rate of Basic Pay
State/Local Government
Salary or "Other" Organization
Salary
14. State/Local Government or "Other" Employees
Original Date Employed by the State/
Local Government or "Other"
Organization (mm-dd-yyyy)
C - POSITION TO WHICH ASSIGNMENT WILL BE MADE
15. Employment Office Name and Address (Building, Street, City, State,
ZIP)
16. Assignee's Position Title
and Position Description
Number
17. Office Phone Number (Area Code)
DS-3034
05-2017
Page 1 of 5
19. Check Appropriate Box
On detail from U.S. Department of State
On leave without pay from U.S. Department of State
On detail to U.S. Department of State (non-Federal employee)
20. Period of Assignment (mm-dd-yyyy)
PART 5: TYPE OF ASSIGNMENT
On appointment in U.S. Department of State (non-Federal employee)
From To
21. Indicate the reasons for this mobility assignment and discuss how the work will benefit the participating organizations. In addition, indicate how the
employee will be utilized at the completion of this assignment.
PART 6: REASON FOR MOBILITY ASSIGNMENT
22. List the major duties and responsibilities to be performed while on the mobility assignment. Attach an accurate and current description of the
position being filled through the IPA assignment.
PART 7: POSITION DESCRIPTION
23. Rate of Basic Pay
PART 8: EMPLOYEE BENEFITS
24. Special Pay Conditions (Indicate any conditions that could increase the assigned employee's compensation
during the assignment period.)
25. Leave Provisions (Indicate the annual and sick leave benefits for which the assigned employee is eligible. Specify the procedures for reporting,
requesting and recording such leave.) Identify, where appropriate, the office to which time and attendance records should be sent.
DS-3034 Page 2 of 5
26. U.S. Department of State Obligations (If paying more than 50 percent
of a Federal employee's salary beyond a 6-month period, specify rationale
for cost-sharing decision.)
IDENTIFY, WHERE APPROPRIATE, THE OFFICE TO WHICH INVOICES SHOULD BE SENT. (BLOCKS 26 OR 27)
PART 9: FISCAL OBLIGATIONS
27. State/Local Government or "Other" Organization or Agency
Obligations
29. The employee has been notified of laws, rules and regulations, and policies on employee conduct which apply while on this assignment.
PART 10: CONFLICTS OF INTEREST AND EMPLOYEE CONDUCT
28. Applicable Federal, State/Local Government or "Other" Organization conflict-of-interest laws have been reviewed with the employee to assure
that conflict-of-interest situations do not inadvertently arise during this assignment.
30. A U.S. Department of State employee on detail to a State/Local
Government or "Other" Organization shall retain all benefits pertaining
to Health, Life Insurance and Medicare. A U.S. Department of State
employee on leave without pay to State/Local Government or "Other"
Organization may retain Health, Life Insurance, and Medicare coverage
if he or she continues to pay the employee contribution through the
U.S. Department of State.
PART 11: BENEFIT OPTIONS
31. State/Local Government or "Other" Organization Benefits (Indicate all
State/Local Government or "Other" Organization employee benefits
that will be retained by the State/Local Government or "Other"
Organization employee being assigned to the U.S. Department of
State. Also include a statement certifying coverage in all State/Local
Government or "Other" Organization employee benefit programs that
are elected by the U.S. Department of State employee on leave
without pay from the U.S. Department of State to a State/Local
Government or "Other" Organization.)
A. Federal Retirement System Coverage (FERS, CSRS, CSRS OFFSET)
I wish to retain my coverage and make appropriate payments.
I do not wish to retain my coverage.
B. Federal Life Insurance Coverage (FEGLI)
I wish to retain my coverage and make appropriate payments.
I do not wish to retain my coverage.
C. Federal Health Benefits Coverage (FEHB)
I wish to retain my coverage and make appropriate payments.
I do not wish to retain my coverage.
32. Other Benefits (Indicate any other employee benefits to be made part of this agreement.)
Page 3 of 5DS-3034
33. Indicate (1) Whether the Bureau/Office in the U.S. Department of State or State or Local government or "Other" organization will pay travel and
transportation expenses to, from, and during the assignment as specified in 3 FAM 2416, and (2) which travel and relocation expenses will be
included.
PART 12: TRAVEL AND TRANSPORTATION EXPENSES AND ALLOWANCES
34. In checking appropriate boxes and signing this agreement in block 35 below, I certify that I understand the terms of this agreement and agree to
the rules, regulations and policies as indicated.
A. The rules and policies governing the internal operation and management of the agency to which my assignment is made under this
agreement will be observed by me.
PART 13: EMPLOYEE CERTIFICATION OF OBLIGATIONS AND RESPONSIBILITIES
B. I have been informed that my assignment may be terminated at any time at the option of the U.S. Department of State or State or Local
government or "Other" organization.
C. I have been informed that any travel and transportation expenses covered from U.S. Department of State appropriations may be
recoverable as a debt due the United States, if I do not serve until the completion of my assignment (unless terminated earlier by either
employer).
D. I have been informed of applicable laws or provisions should my position with my permanent employer become subject to a
reduction-in-force.
E. (For U.S. Department of State employees only) I agree to serve with the U.S. Department of State upon the completion of my assignment
for a period equal to that of my assignment. Should I fail to serve the required time, I have been informed that I may be liable to the U.S.
Department of State for all expenses (except salary and benefits) of my assignment.
F. I have been notified of possible impact pertaining to retirement health and life insurance benefits depending on the type of assignment,
e.g., detail, leave without pay.
35. Typed Name and Signature of Employee Date of Signature (mm-dd-yyyy)
36. Typed Name, Title, and Signature of Recommending Official (Supervisor) Date of Signature (mm-dd-yyyy)
In approving this agreement, you certify that:
- the description of duties and responsibilities is current and fully and accurately describes those of the assigned employee; and
- this assignment is being entered into to serve a sound, mutual public purpose and not solely for the employee's benefit; and
- at the completion of the assignment, the participating employee will be returned to the position he or she occupied at the time this agreement was
entered into or a position of like grade and pay.
PART 14: CERTIFICATION OF APPROVING OFFICIALS
37. BUREAU ASSISTANT SECRETARY OR DESIGNEE
Approved Disapproved
Typed Name, Title, and Signature Date of Signature (mm-dd-yyyy)
38. STATE/LOCAL GOVERNMENT OR "OTHER" ORGANIZATION APPROVING
Approved Disapproved
Typed Name, Title, and Signature Date of Signature (mm-dd-yyyy)
39. DIRECTOR, OFFICE OF CIVIL SERVICE HUMAN RESOURCE MANAGEMENT
Approved Disapproved
Typed Name, Title, and Signature Date of Signature (mm-dd-yyyy)
Page 4 of 5DS-3034
DIRECTOR GENERAL OF THE FOREIGNSERVICE AND DIRECTOR OF HUMAN RESOURCESOR DESIGNEE
Approved Disapproved
Typed Name, Title, and Signature Date of Signature (mm-dd-yyyy)
40.
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 5 of 5DS-3034
Use this page as a continuation sheet. Indicate the number of the question and then provide the corresponding information:
CONTINUATION SHEET
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome