18. Immediate Supervisor (Name and Title)
U.S. Department of State
INTERGOVERNMENTAL PERSONNEL ACT AGREEMENT
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.
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?
5b. If yes, please provide the dates of each assignment (mm-dd-yyyy)
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?
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
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
Salary or "Other" Organization
14. State/Local Government or "Other" Employees
Original Date Employed by the State/
Local Government or "Other"
C - POSITION TO WHICH ASSIGNMENT WILL BE MADE
15. Employment Office Name and Address (Building, Street, City, State,
16. Assignee's Position Title
and Position Description
17. Office Phone Number (Area Code)
Page 1 of 5