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# PAYROLL AUTHORIZATION FORM(Please Use Typewriter or Ballpoint Pen) U.S. HOUSE OF REPRESENTATIVES Washington, D.C. 20515 (Any erasures, corrections, or changes on this form must be initialed by the authorizing official.)To the Clerk of the House of Representatives:I hereby authorize the following payroll action:| Employee Name (First-Middle-Last)          | Effective Date                                                                                                || ------------------------------------------ | ------------------------------------------------------------------------------------------------------------- || Charles Michael Rerk                       | 12/31/78                                                                                                      || Employee Social Security Number            | Type of Action                                                                                                || 290-50-4529                                | ☐ 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 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 256 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 January 2 1979LOUIS STOKES(Signature of Authorizing Official)CHAIRMAN(Type or print name of Authorizing Official)(Title - If Member, District and State)(If appropriate, signature of Subcommittee Chairman or Ranking Minority Member)(Type or print name and title of above official)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 Administration| Office of Finance use only:                      | ID                 || ------------------------------------------------ | ------------------ || Office Code__________                            | Benefits__________ || Monthly Annuity $___________.00 as of __________ | Payroll__________  |Copy for Initiating Office or Committee (Revised: August 1, 1977)NW 88326DocId:32243272 Page 3