Form 12114 Continuation Sheet for Item # 16 (Additional Information

Department of the Treasury - Internal Revenue Service

Form 12114 (Rev. 3-2005)
Catalog Number 26601R

Continuation Sheet for Item # 16 (Additional Information)
OF-306, Declaration for Federal Employment

OMB Number 1545-1921

Read the background Information Section of OF-306 very carefully, the requested information must be provided.
If your answer is ''yes'' to questions 9, 10, 11, 12, or 13, please make sure the following details are included in your explanation
in Item # 16 on the OF-306, this continuation sheet, or you may use an additional sheet of paper.
If you use this continuation sheet, the reverse side of this sheet, or an additional sheet of paper to provide additional
information, be sure to sign and list your social security number and date on each additional sheet used.

Additional Information Provided - Needed Only if You Answered Yes to Questions 9-13
Item 9, 10, or 11 - If you answered yes to Items 9, 10, or 11, please complete information below.
Date of the violation

Explanation of the violation

What was the charge?
Were you convicted?

Yes

No

What were the results? Were you;

Continued on reverse
fined?

Incarcerated?

put on probation?

Name and complete address of police
department or court involved.

Continued on reverse

Are you currently under any charges for any violation of law or are you on probation?
Yes (If yes, please explain)

No
Continued on reverse

Item 12 - if you answered yes to Item 12, please specify below
Date

Employer's name and address

Explanation of problem and reason for leaving:

Continued on reverse

Item 13 - if you answered yes to Item 13 please specify below
Type of debt (student loan, federal taxes, etc.)

Date debt began

Balance due

Steps that you are taking to correct the error or repay the debt.

Continued on reverse
Applicants signature

SSN

Date

Privacy Act and Paperwork Reduction Act Notices
Under Executive Order 9397, Federal agencies were required to use the Social Security Number (SSN) as a means of identifying
individuals in personnel record systems. Solicitation of your SSN is thus authorized by this executive order and will be used to ensure
that the information you provide is accurately recorded as pertaining to you. Furnishing your SSN or any of the other data is voluntary,
but failure to supply complete and accurate information may limit consideration or jeopardize eligibility to hold a Federal position. The
information requested on this form will be used to update personnel records. Your name and/or social security number is only used as
an identifier (authorized under Executive Order 9397, dated November 1943.) Your response is voluntary. We ask for the information on
this form to carry out the mission of the Internal Revenue Service. We need the information to process your application for employment
with the Internal Revenue Service. You are not required to provide the information requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by code section 6103. The time needed to complete this form will vary depending upon
the individual circumstances. The estimated average time to complete this form is 15 minutes. If you have comments concerning the
accuracy of this estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Internal
Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.

Catalog Number 26601R