VETERAN STATUS INFORMATION

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<tbody>
<tr class="odd">
<td colspan="30"><strong>DO NOT WRITE IN THIS SPACE</strong></td>
</tr>
<tr class="even">
<td colspan="30"><blockquote>
<p> Nonveteran Undisabled Veteran Compensable Disabled Veteran
<u>     </u>% Derivative Preference Veteran</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="30"><blockquote>
<p> Retired Veteran - No preference in reductions in-force</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="30"><blockquote>
<p>Documentary evidence including dates of military, service reviewed;
the status checked above determined.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="11">Certified by:</td>
<td colspan="12">     </td>
<td colspan="4">Date</td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="30"></td>
</tr>
<tr class="odd">
<td colspan="30"></td>
</tr>
<tr class="even">
<td colspan="30"><strong>Instructions:</strong> Please complete this
form in blue or black ink. Submit forms and appropriate documentation to
Shared Resources Staffing and Recruiting, 1101 Market Street, EB 8B,
Chattanooga, Tennessee 37402.</td>
</tr>
<tr class="odd">
<td colspan="30"><strong>Part 1: Identifying Information</strong></td>
</tr>
<tr class="even">
<td>1.</td>
<td colspan="6">Social Security Number</td>
<td colspan="11">     </td>
<td colspan="7">Date</td>
<td colspan="4">     </td>
<td></td>
</tr>
<tr class="odd">
<td>2.</td>
<td colspan="2">Last Name</td>
<td colspan="8">     </td>
<td colspan="4">First</td>
<td colspan="5">     </td>
<td colspan="5">Middle</td>
<td colspan="4">     </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="24">Permanent Address:</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td>3.</td>
<td colspan="10">P.O. Box or Street No. and Street Name</td>
<td colspan="18">     </td>
<td></td>
</tr>
<tr class="even">
<td>4.</td>
<td>City</td>
<td colspan="8">     </td>
<td colspan="3">County</td>
<td colspan="6">     </td>
<td colspan="3">State</td>
<td colspan="4">     </td>
<td colspan="2">Zip Code</td>
<td>     </td>
<td></td>
</tr>
<tr class="odd">
<td>5.</td>
<td colspan="8">Area Code/Telephone Number</td>
<td colspan="9">     </td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td>6.</td>
<td colspan="8">Type of work or position desired</td>
<td colspan="20">     </td>
<td></td>
</tr>
<tr class="odd">
<td>7.</td>
<td colspan="12">At which location would you accept employment?</td>
<td colspan="16">     </td>
<td></td>
</tr>
<tr class="even">
<td>8.</td>
<td colspan="28">Have you previously worked for TVA? Yes No</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="12">If “Yes,” provide the dates worked and location:</td>
<td colspan="16">     </td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="29"></td>
</tr>
<tr class="odd">
<td colspan="30"><strong>Part 2: All preference claimants must complete
Parts 1 and 2, sign Part 4 and provide with this application form
DD214<br />
and proof of campaign award, and/or current disability
status.</strong></td>
</tr>
<tr class="even">
<td>9.</td>
<td colspan="15">Name of veteran whose service preference is
claimed</td>
<td colspan="13">     </td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="15"></td>
<td colspan="13"><em>(type or print name exactly as it appears on
discharge form):</em></td>
<td></td>
</tr>
<tr class="even">
<td>10.</td>
<td colspan="29">Is the veteran deceased? Yes No</td>
</tr>
<tr class="odd">
<td>11.</td>
<td colspan="8">If deceased, give date of death</td>
<td colspan="8">     </td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td>12.</td>
<td colspan="29">Does the veteran have an existing disability recognized
by the Veterans’ Administration as service-connected?</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4"> Yes No</td>
<td colspan="16">If “Yes,” give claim number here and provide current
evidence*</td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="even">
<td>13.</td>
<td colspan="29">Is the veteran receiving payment from the Veterans’
Administration due to a service-connected disability? Yes No</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="29">If “Yes,” provide current evidence.*</td>
</tr>
<tr class="even">
<td>14.</td>
<td colspan="29">Is the veteran receiving a pension or disability
retirement benefits from the Veterans’ Administration or from a branch
of the</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="23">Armed Forces? Yes No Give V.A. claim number here and
provide evidence*</td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td>15.</td>
<td colspan="29">Has veteran been awarded the Purple Heart for
wounds/injuries received in action? Yes No</td>
</tr>
<tr class="odd">
<td>16.</td>
<td colspan="29">Which are you? <em>(check one)</em> A. The veteran B.
The veteran’s widow or widower**</td>
</tr>
<tr class="even">
<td></td>
<td colspan="29"> C. The wife or husband of a disabled veteran** D. The
mother of a deceased or disabled veteran**</td>
</tr>
<tr class="odd">
<td>17.</td>
<td colspan="29">Was the veteran’s service in peace time only? Yes
No</td>
</tr>
<tr class="even">
<td>18.</td>
<td colspan="29">If the answer to question 17 is “Yes,” was campaign or
expeditionary medal authorized? Yes No</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5">Name of campaign:</td>
<td colspan="23">     </td>
<td></td>
</tr>
<tr class="even">
<td>19.</td>
<td colspan="5">Branch of Service</td>
<td colspan="23">     </td>
<td></td>
</tr>
<tr class="odd">
<td>20.</td>
<td colspan="11">Date of entry (or entries) into Armed Forces</td>
<td colspan="17">     </td>
<td></td>
</tr>
<tr class="even">
<td>21.</td>
<td colspan="12">Date of separation (or separations) from service</td>
<td colspan="16">     </td>
<td></td>
</tr>
<tr class="odd">
<td>22.</td>
<td colspan="7">Rank at time of separation(s)</td>
<td colspan="21">     </td>
<td></td>
</tr>
<tr class="even">
<td>23.</td>
<td colspan="3">Serial Number</td>
<td colspan="12">     </td>
<td colspan="14"></td>
</tr>
<tr class="odd">
<td>24.</td>
<td colspan="13">Number of days of lost time (AW 107; A 86; AWOL)</td>
<td colspan="15">     </td>
<td></td>
</tr>
<tr class="even">
<td>25.</td>
<td colspan="29">Were all separations under honorable conditions? Yes No
If “No,” give details on separate sheet.</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="29"></td>
</tr>
</tbody>
</table>

  ------------ ---------------------- ------- -- ------- ------------ -- ------------ ------ ------- ------------- -- --
  **Part 3:                                                                                                           
  Complete if                                                                                                         
  Retired                                                                                                             
  Military**                                                                                                          

  26\.         If applicant/employee                                                                                  
               is a retired member of                                                                                 
               the uniformed                                                                                          
               services, provide the                                                                                  
               following information:                                                                                 

               Uniformed service from                                    Rank at                                      
               which retired                                             retirement                                   

  27\.         Is retirement from the                                                                                 
               uniformed service                                                                                      
               based upon disability                                                                                  
               (1) resulting from                                                                                     
               injury or disease                                                                                      
               received in the line                                                                                   
               of duty as                                                                                             

               a direct result of                                                                                     
               armed conflict, or (2)                                                                                 
               caused by an                                                                                           
               instrumentality of war                                                                                 
               and incurred in the                                                                                    
               line of duty during a                                                                                  
               period of war                                                                                          

               (see III REDUCTION,                                                                                    
               Salary Policy, for                                                                                     
               definition of "period                                                                                  
               of war")? Yes No                                                                                       

  28\.         Is retirement based on                                                                                 
               credit for at least                                                                                    
               twenty years of                                                                                        
               full-time active                                                                                       
               service (regardless of                                                                                 
               when performed but not                                                                                 
               including                                                                                              

               periods of active duty                                                                                 
               for training)? Yes No                                                                                  

  29\.         Will you be eligible                                                                                   
               in the future to                                                                                       
               retire from an                                                                                         
               uniformed service? Yes                                                                                 
               No                                                                                                     

               Uniformed service from                                                                                 
               which you will retire                                                                                  

               Approximate date of                                                                                    
               retirement eligibility                                                                                 

                                                                                                                      

  **Part 4:                                                                                                           
  All                                                                                                                 
  Preference                                                                                                          
  Claimants                                                                                                           
  must sign                                                                                                           
  here**                                                                                                              

                                                                                                                      

               I certify that the                                                                                     
               statements made by me                                                                                  
               in answer to all                                                                                       
               questions on this form                                                                                 
               are true to the best                                                                                   
               of my knowledge and                                                                                    
               belief.                                                                                                

                                                                                                                      

               Signature                                                              Date                            

                                                                                                                      

               Proof to support                                                                                       
               applicant's claim for                                                                                  
               veteran's preference                                                                                   
               must be submitted with                                                                                 
               this form prior to                                                                                     
               closing date of job.                                                                                   

                                                                                                                      
  ------------ ---------------------- ------- -- ------- ------------ -- ------------ ------ ------- ------------- -- --

**\*** Except for claim based on award of Purple Heart, for disability
preference you must present documentary evidence at the time application
is made (generally, a letter from the Veteran Affairs Office dated
within the last 12 months stating the percentage of disability).

**\*\*** If you are claiming preference as the spouse of a veteran who
has a service-connected disability, a veteran's widow or widower who has
not remarried, or as a widowed, divorced, or separated mother of a
deceased or totally disabled veteran who was honorably discharged,
please complete the appropriate part on page 2 of this form.

**Derivative Preference Information**

(Complete only if you are claiming veterans preference as spouse,
widow/widower, or mother of veteran.)

  ------------------- ------------------- ------------- ------- ------- ------- ------- ---- ------- -------------------- --
  **Part 5: Spouse of                                                                                                     
  Veteran with                                                                                                            
  Service-Connected                                                                                                       
  Disability**                                                                                                            

  30\.                Are you presently                                                                                   
                      married to the                                                                                      
                      veteran? Yes No                                                                                     

                      (If "No," you are                                                                                   
                      ineligible for this                                                                                 
                      preference and need                                                                                 
                      not complete the                                                                                    
                      questions below).                                                                                   

  31\.                Is the veteran                                                                                      
                      currently working?                                                                                  
                      Yes No If "No," go                                                                                  
                      to item 33.                                                                                         

  32\.                If currently                                                                                        
                      working, what is                                                                                    
                      the veteran's                                                                                       
                      present occupation?                                                                                 

  33\.                What was the                                                                                        
                      veteran's                                                                                           
                      occupation, if any,                                                                                 
                      before military                                                                                     
                      service?                                                                                            

  34\.                What was the                                                                                        
                      veteran's military                                                                                  
                      occupation at the                                                                                   
                      time of separation?                                                                                 

  35\.                Has the veteran                                                                                     
                      been employed, or                                                                                   
                      is he/she now                                                                                       
                      employed by the                                                                                     
                      Federal civil                                                                                       
                      service or DC                                                                                       
                      Government? Yes No                                                                                  

                      A. Title and grade                                                                                  
                      of position most                                                                                    
                      recently or                                                                                         
                      currently held                                                                                      

                      B. Name and Address                                                                                 
                      of Agency                                                                                           

                      C. Dates of                                                       To                                
                      employment: From                                                                                    

  36\.                Has the veteran                                                                                     
                      resigned from, been                                                                                 
                      disqualified for,                                                                                   
                      or separated from a                                                                                 
                      position in the                                                                                     
                      Federal civil                                                                                       
                      service or DC                                                                                       

                      Government along                                                                                    
                      the lines of                                                                                        
                      his/her usual                                                                                       
                      occupation because                                                                                  
                      of                                                                                                  
                      service-connected                                                                                   
                      disability? Yes No                                                                                  

                      If "Yes," submit                                                                                    
                      documentation of                                                                                    
                      the resignation,                                                                                    
                      disqualification,                                                                                   
                      or separation.                                                                                      

  37\.                Is the veteran                                                                                      
                      receiving a civil                                                                                   
                      service retirement                                                                                  
                      pension? Yes No                                                                                     

                      If "Yes," give the                                                                                  
                      Civil Service or                                                                                    
                      Federal Employee                                                                                    
                      retirement annuity                                                                                  
                      number                                                                                              

                                                                                                                          

  **Part 6:                                                                                                               
  Widow/Widower of                                                                                                        
  Veteran**                                                                                                               

  38\.                Were you married to                                                                                 
                      the veteran listed                                                                                  
                      in Part 2 when                                                                                      
                      he/she died? Yes No                                                                                 

  39\.                Have you remarried?                                                                                 
                      Yes No                                                                                              

  40\.                Did the veteran die                                                                                 
                      while on active                                                                                     
                      duty? Yes No                                                                                        

                                                                                                                          
  ------------------- ------------------- ------------- ------- ------- ------- ------- ---- ------- -------------------- --

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+---+-------------------------------------------------------------------+
| 4 | Is the veteran your natural child? Yes No                         |
| 1 |                                                                   |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
|   | (Preference cannot be granted on the service of a stepchild,      |
|   | foster child, or adopted child.)                                  |
+---+-------------------------------------------------------------------+
| 4 | Is the natural father of your child *(check one):*                |
| 2 |                                                                   |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
|   | A. Living with you? B. Deceased? C. Divorced from you? D.         |
|   | Separated from you?                                               |
+---+-------------------------------------------------------------------+
| 4 | Is the natural father of your child *(or the husband of your      |
| 3 | remarriage)* with whom you are now living totally and permanently |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
|   | disabled? Yes No                                                  |
+---+-------------------------------------------------------------------+
| 4 | If natural father or veteran is deceased or divorced from you,    |
| 4 | have you remarried? Yes No                                        |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
| 4 | Are you widowed, divorced, or legally separated from the husband  |
| 5 | of your remarriage? Yes No                                        |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
| 4 | If the veteran is deceased, did he/she lose his/her life under    |
| 6 | honorable conditions while on active duty either during a war,    |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
|   | between April 28,1952 and June 30, 1955, or in a campaign or      |
|   | expedition for which a campaign medal has been authorized?        |
+---+-------------------------------------------------------------------+
|   | Yes No (If "Yes," submit death certificate from armed forces.)    |
+---+-------------------------------------------------------------------+
| 4 | If the veteran is still living, was he or she separated with an   |
| 7 | honorable or a general discharge? Yes No                          |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
| 4 | Is the veteran permanently and totally disabled? Yes No If "Yes," |
| 8 | provide documentation of disability.                              |
| \ |                                                                   |
| . |                                                                   |
+---+-------------------------------------------------------------------+
|   |                                                                   |
+---+-------------------------------------------------------------------+
|   |                                                                   |
+---+-------------------------------------------------------------------+
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+---+-------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Privacy Act Statement**                                             |
|                                                                       |
| Subsection (e) (3) of 5 U.S.C. ξ 522a (Section 3 of the Privacy Act)  |
| requires that TVA inform you of its authority to request information  |
| and the uses which TVA may make of the information requested. That    |
| subsection further requires TVA to inform you of the effects of not   |
| providing any or all of the requested information.                    |
|                                                                       |
| TVA's authority to request the information you will provide is        |
| derived from the TVA Act and the Veterans Preference Act of 1944, as  |
| amended, and will be used to determine your preference eligibility    |
| status. Information provided on the form may be furnished to people,  |
| agencies, organizations, or institutions in order to verify such      |
| status.                                                               |
|                                                                       |
| Furnishing the requested information is voluntary; however, failure   |
| to provide all or part of the information and documentation requested |
| may result in a lack of further consideration for employment, your    |
| preference status not being considered, or in the termination of your |
| employment.                                                           |
|                                                                       |
| Information provided on this form is normally used only to determine  |
| eligibility for veterans preference. Information obtained on this     |
| form may be furnished to third parties as authorized by law. For      |
| example, should a dispute arise or a congressional inquiry be made    |
| regarding TVA employment practices, the information may be made       |
| available outside of TVA in the course of that dispute or inquiry.    |
| Further, information on this form may be made available to law        |
| enforcement agencies in the exercise of their duties, or to a         |
| prospective employer or TVA contractor upon proper request.           |
+-----------------------------------------------------------------------+

**Distribution:** Original - ESC