[180-10071-10001.pdf — page 3]
# 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                                                                                         || ------------------------------------------ | ------------------------------------------------------------------------------------------------------ || Donald A. Furdy, Jr.                       | 12/31/78                                                                                               || Employee Social Security Number            | Type of Action                                                                                         || 211-38-9707                                |                                                                                                        || Employing Office or Committee/Subcommittee |                                                                                                        || Assassinations                             | ☐ Appointment                                                                                          ||                                            | ☐ Salary Adjustment                                                                                    ||                                            | ☐ 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. 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 January 2 19 79(Signature of Authorizing Official)LOUIS STOKES(If appropriate, signature of Subcommittee Chairman or Ranking Minority Member) (Type or print name of Authorizing Official)CHAIRMAN(Type or print name and title of above 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 CodeMonthly Annuity $___________.00 as ofCopy for Initiating Office or CommitteeIDBenefitsPayroll (Revised: August 1, 1977)NW 88326Docld:32244443 Page 4