[180-10068-10362.pdf — page 2]
# PAYROLL AUTHORIZATION FORM(Please Use Typewriteror Ballpoint Pen)U.S. HOUSE OF REPRESENTATIVESWashington, D.C. 20515(Any erasures, corrections, or changeson this form must be initialed by theauthorizing official.)To the Clerk of the House of Representatives:I hereby authorize the following payroll action.| Employee Name (First-Middle-Last)          | Effective Date                                                                                                      || ------------------------------------------ | ------------------------------------------------------------------------------------------------------------------- || Charlotte Green                            | 7/31/78                                                                                                             || Employee Social Security Number            | Type of Action                                                                                                      || 148-52-9861                                | ☐ Appointment                                                                                                       || Employing Office or Committee/Subcommittee | ☐ Salary Adjustment                                                                                                 || Assassinations                             | ☐ Title Change                                                                                                      ||                                            | ☑ Termination (Aí close of business on effective date)                                                              ||                                            | ☐ Leave without pay (Beginning with effective date above and ending close of business________ Specify Date________) |(If type of action is an Appointment, Salary Adjustment, or Title Change, complete appropriate information below.)| Position Title | Gross Annual Salary* || -------------- | -------------------- |* If employee is a civil service annuitant (includes U.S. House of Representatives), the gross annual salary shown should include the annuity received by the employee plus the salary received from the employing office.(If Committee Employee, complete appropriate item below.)1. ☐ Standing Committee: Staff ☐ Clerical or ☐ Professional.2. ☑ Special (Investigative staff of Standing Committee) or Select Committee: Authority-H. Res. 956_of 95th Congress.3. ☐ Joint Committee.(If Employee of an Officer of the House, complete item below.)Position Number_________ If applicable, Level_________ Step________I certify that this authorization is not in violation of 5 U.S.C. 3110(b), prohibiting the employment of relatives.Date August 10 19 78(If appropriate, signature of Subcommittee Chairman or Ranking Minority Member) (Signature of Authorizing Official)LOUIS STOKES, CHAIRMAN(Type or print name and title of above official) (Type or print name of Authorizing Official)(Title-If Member, District and State)All appointments and salary adjustments for employees under the House Classification Act and for Committee employees, except those of the Committee on Appropriations, the Committee on the Budget, and the Joint Committees, must be approved by the Committee on House Administration.APPROVED:Chairman, Committee on House AdministrationOffice of Finance use only:Office Code________Monthly Annuity $_________.00 as of ________ID ________Benefits ________Payroll ________Copy for Initiating Office or Committee(Revised: August 1 1977)NW 88326DocId:32243328 Page 3