Self Certification of Continuous Service REV 02-12-2025.pdf
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- Solicitation number
- 36C26326B0020
About this file
This is a self-certification form issued by the Department of Veterans Affairs, Personnel Security Adjudication Center, used to document an individual's break in service from federal employment. The form requires the applicant to select one of four options regarding their break in service status: no break in service, a break of less than 24 months, a break greater than 36 months but less than 60 months, or a break greater than 60 months or no prior federal employment. For options involving a break in service, applicants must provide the date they left federal employment.
Federal employment is defined broadly to include any branch of the United States military (Active, Guard, or Reserve), federal government civilian employees from any federal agency, or contractors working for the federal government. The form requires the applicant's full name, Social Security number, signature, and date of completion. The current version was revised June 27, 2025, with all previous versions declared obsolete.
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Text version
DEPARTMENT OF VETERANS AFFAIRS
OPERATIONS, SECURITY, AND PREPAREDNESS
PERSONNEL VETTING AND CREDENTIAL MANAGEMENT
PERSONNEL SECURITY ADJUDICATION CENTER
Self Certification of Continuous Service
I hereby certify my break in service from my last federal employment is indicated by the block checked below.
I have NOT had a break in service.
My break in service is less than 24 months.
[Date I left federal employment was _____________.]
My break in service is greater than 36 months, but less than 60 months. [Date I left federal employment was _____________.]
My break in service is greater than 60 months; or I have never had federal employment as defined above.
Full Name: Social Security Number:
Signature: Date:
(Select One)
Federal employment is defined as any branch of the United States military (Active, Guard or Reserve), federal government civilian employee (any federal government agency), or a contractor working for the federal government.
Self Certification of Continuous Service Form Revised June 27, 2025
Previous Versions are Obsolete
| I have NOT had a break in service: Off |
| Print Name: |
| Social Security Number: |
| My break in service was less than 36 months: Off |
| My break in service is greater than 36 months, but less than 60 months: Off |
| My break in service is greater than 60 months or I have never worked: Off |
| Date of Form Completion_af_date: |
| Date Left Federal Employment 1_af_date: |
| Date Left Federal Employment 2_af_date: |
File details come from the government source that posted it. Updated .