Block 1

Personnel Office Sequential Request Number

Enter the Agency-assigned sequential number to identify the payroll action request. The first request of the year should start with one. Thereafter, each request is assigned the next number in ascending order. Each leave year, a new series of numbers is issued.

Block 2

Adjustment Period (Inclusive), From: Date P/P, To: Date P/P

Enter the inclusive dates and pay periods for the adjustment. When the request for an adjustment or correction involves 1 or more previous pay periods, a detailed description is displayed in Block 13, Explanation of Circumstances Which Require This Action.

Block 3

Instructions on Reverse of Agency Copy Please Read Carefully

Do not enter any information in this block.

Block 4

From: Agency Code, Personnel Office Identifier, Acct. Station Code, Agency Name and Mailing Address, City, State, Zip Code

Enter the two-digit Agency code assigned by the Department.
Enter the four-digit code assigned by the Agency to the personnel office responsible for processing personnel and other related documents for the employee for the Personnel Office Identifier.
Enter the four-digit accounting station code assigned as the Agency Accounting Station Code.
Enter the full name and address of the office preparing the request in the Agency Name and Mailing Address.

Note: Ensure that the information is shown correctly, since future correspondence will be sent to the address identified in this block.

Block 5

Employee’s T&A Contact Point

Enter the applicable contact-point code to identify the Agency office where NFC National Finance Center can direct inquiries about T&A Time and Attendance reports.

Block 6

FLSA

Check the exempt box for employees not covered under the Fair Labor Standards Act (FLSA). Check the non-exempt box for employees covered under FLSA Fair Labor Standards Act.

Block 7

Retirement Coverage Code

Enter the code to indicate if the employee’s appointment is subject to Federal Insurance Contributions Act (FICA) or retirement deductions at the appropriate percentage rate. Annotate whether the employee is Civil Service Retirement System (CSRS), CSRS Offset, or Federal Employees Retirement System (FERS).

Block 8

Type Employment

Check the block that indicates the employee’s type of employment (full-time, intermittent, reemployed annuitant, part-time, alternate work schedule).

Block 9

Social Security No.

Enter the employee’s Social Security number (SSN) to ensure the action is processed against the correct record. No entry or an incorrect entry will result in a processing delay. If the request involves more than 1 pay period or employee, enter See Attachment and list the names, SSN Social Security numbers, and pay periods on an attachment.

Block 10

Employee’s Name (Last, First, Middle Initial)

Enter the employee’s full name as it appears on the employee’s Standard Form (SF) 50, Notification of Personnel Action (Last, First, Middle Initial). If the request involves more than one employee, enter See Attachment and list the names and SSN Social Security numbers on an attachment.

Block 11

Nature of Action To Be Taken

Enter a description of the type of action to be taken. Enter detailed explanations in Block 13, Explanation of Circumstances Which Require This Action. If an employee has different transactions, a separate Form AD-343, must be used.

Block 12

Terminated

Check the appropriate block, if applicable. If the employee was terminated, enter the date terminated. Enter the employee’s mailing address. If check is to be mailed to a designated agent, enter the Agency assigned four-digit Agency number.

Block 13

Explanation of Circumstances Which Require This Action

Enter the detailed explanation of the transaction. Include specific dates if applicable. For additional space, use a separate sheet and enter See Attachment.

Block 14

Gross Amount of Adjustment

Enter the gross amount of the adjustment, if available.

Block 15

Accounting Data To Be Charged and/or Credited

Enter the appropriate accounting code to be used on the amounts entered in Block 13, Explanation of Circumstances Which Require This Action. If the charges or credits affect multiple accounting distributions, each must be entered. If the correction involves a number of line items, enter See Attachment and list the data on an attachment. Also enter the dollar amounts or hours for each line item. In addition to these entries, include the object classification code(s) used for the payment transactions.

Block 16

Attachments Supporting or Authorizing This Action

Enter a detailed description of each attached document that relates to or authorizes the action. Also, show in parentheses the number of documents attached.

Block 17

Person To Be Contacted for Additional Information, Telephone

Enter the name and telephone number of the person that NFC National Finance Center should contact for additional information.

Block 18

Employee’s Signature and Date Signed (If Required)

Sign and date this block only if the regulations require consent from the employee. This action is taken by the employee.

Block 19

Approval

Sign and enter your official title as the Approving Official. This action is required by the authorized office. Additionally, the date approved must be entered.