SPECIAL AGREEMENT CHECK (SAC)Special Agreement • January 18th, 2002
Contract Type FiledJanuary 18th, 2002Agency Agreement Number OPM USE ONLY OPM Codes Case Number AGENCY USE ONLY (COMPLETE ITEMS 1 THROUGH 14 USING INSTRUCTIONS FROM THE BACK) 1.SUBJECT’S FULL NAME 2. DATE OF BIRTH Last Name First Name Middle Name (Suffix) Month Day Year 3. PLACE OF BIRTH (Use the two letter code for the State) 4. SOCIAL SECURITY NUMBER City County State Country 5. OTHER NAMES USED AND DATES WHEN USED Name From Month Year To Month Year Name From Month Year To Month Year Name From Month Year To Month Year Name From Month Year To Month Year 6. SEX (Mark one box)❑ Female❑ Male 7. SPECIAL AGREEMENT CODES S 8. POSITION TITLE 9. SON 10. SOI 11. OPAC-ALC Number 12. Accounting Data