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CERTIFICATE OF ADMINISTRATIVE OFFICER

THIS IS TO CERTIFY that [[blank]], born [[blank]], applicant for service credit, is now and has since [[blank]] been employed as [[blank]] (Position) in [[blank]] (Department, branch, or independent office) at [[blank]] (Location) and that deductions have been made from his salary for the retirement fund since [[blank]]

SCHEDULE 1
That the following is a schedule of employment since August 1, 1920, for which service credit is claimed: (State whether compensation was on an annual, monthly, daily, hourly, or piecework basis. Do not include bonuses, allowances, overtime pay, nor salary, pay, or compensation given in addition to the base pay of the positions as fixed by law or regulation. Do not include in this schedule rate of pay covering periods for which refund has been made. See par. 8 of General Instructions on p.4.) 

[[10 column chart]]
|DEPARTMENT, BRANCH, OR INDEPENDENT OFFICE |BEGINNING Month |BEGINNING Day |BEGINNING Year |ENDING Month |ENDING Day |ENDING Year |RATE Dollars | RATE Cents | PER-|
[[blank]]

SCHEDULE 2
That the following is a statement showing the aggregate basic salary, pay, or compensation paid the applicant by fiscal years during period for which service credit is claimed: (Do not include in this schedule periods for which refund has been made. See par. 9 of General Instructions on p. 4.)

[[12 column chart]]
|FISCAL YEAR ENDING-|PERIOD IN SERVICE BEGINNING Month |PERIOD IN SERVICE BEGINNING Day |PERIOD IN SERVICE BEGINNING Year |PERIOD IN SERVICE ENDING Month |PERIOD IN SERVICE ENDING Day |PERIOD IN SERVICE ENDING Year| AGGREGATE BASIC SALARY, PAY, OR COMPENSATION (100%)|   |THIS SPACE RESERVED FOR THE CIVIL SERVICE COMMISSION|   |   |
[[blank]]


|June 30, 1921|   |   |   |   |   |   |$|   |   |   |   |
|June 30, 1922|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1923|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1924|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1925|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1926|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1927|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1928|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1929|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1930|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1931|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1932|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1933|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1934|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1935|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1936|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1937|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1938|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1939|   |   |   |   |   |   |   |   |   |   |   |
|June 30, 1940|   |   |   |   |   |   |   |   |   |   |   |

1. During the above period, the applicant was employed the major portion of every calendar month subsequent to June 30, 1930, except [[blank]]
2. During the time for which credit is claimed, the applicant was absolutely separated from the civil service for the following period or periods: [[blank]]
3. Deductions were not made because of [[blank]] (State whether temporary, excepted, or unclassified status, or administrative error)

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