Free 53665ig.FH11 - Indiana

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POSITION DATA CHANGE WORKSHEET
State Form 53665 (6-08) Date (month, day, year)

INSTRUCTIONS: This form is not to be utilized for normal comensation requests (i.e. above min, reclassification, etc). It is only intended to be utilized for the purpose of requesting: 1) Location Code Changes, 2) Department ID Changes, 3) Fund Center Changes, and/or 4) Reports to Changes. Bus Unit Merit / Non-Merit Reg / Int / Temp Old Reports To New Reports To New Dept ID New Loc Code Old Fund Center New Fund Center Effective Date

PCN

Incumbent

FT / PT

JUSTIFICATION FOR DEPARTMENT ID AND/OR LOCATION CODE CHANGES