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# PAYROLL AUTHORIZATION FORM(Please Use Typewriter U.S. HOUSE OF REPRESENTATIVES (Any erasures, corrections, or changesor Ballpoint Pen)Washington, D.C. 20515 on 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                                                      || ------------------------------------------ | ------------------------------------------------------------------- || Jeffrey Factor                             | April 1. 1978                                                       || Employee Social Security Number            | Type of Action                                                      || 341-44-6951                                | ☐ Appointment                                                       || Employing Office or Committee/Subcommittee | ☐ Salary Adjustment                                                 || Assassinations                             | ☐ Title Change                                                      ||                                            | ☑ Termination (At 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 shoüld 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 95 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 April 11, 19 78(Signature of Authorizing Official)LOUIS STOKES(If appropriate, signature of Subcommittee Chairman or Ranking Minority Member)(Type or print name of Authorizing Official)(Type or print name and title of above official)CHAIRMAN(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__________Copy for Initiating Office or CommitteeID__________Benefits__________Payroll__________ (Revised: August 1977)NW 88326DocId:32243310 Page 5