Da Form 3715 R – Fill Out and Use This PDF

US ARMY NONAPPROPRIATED FUNDS – DISPOSITION OF RETIREMENT BENEFITS

For use of this form, see AR 215-3; the proponent agency is DCSPER

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:Internal Revenue Service Code, Section 401(a)

PRINCIPAL PURPOSE: The information you provide is for the purpose of preparing a refund of contributions or to process a retirement annuity

ROUTINE USES:For terminating employees, the information is used to prepare a refund or a deferred annuity as requested. For retirement employees,

the information is used to process am monthly annuity payment thereafter. For survivors, the information is used to process survivor benefits.

DISCLOSURE:Disclosure of your social security number and primary insurance amount is voluntary. Disclosure of other personal information is voluntary, however, failure to provide this information within one year of termination of employment will result in automatic refund of contributions and denial of annuity.

SECTION I - GENERAL INFORMATION

EMPLOYEE NAME (LAST, FIRST, MI)			SOCIAL SECURITY NUMBER	DATE OF BIRTH
COMPLETE MAILING ADDRESS (STREET, CITY, STATE, ZIP)				TELEPHONE #
SERVICE COMPUTATION DATE			DATE OF SEPARATION AND REASON	SICK LEAVE HRS
EMPLOYING NAFI
MARITAL STATUS			NAME OF LEGAL SPOUSE (LAST, FIRST, MI)
SOCIAL SECURITY NUMBER OF LEGAL SPOUSE			DATE OF BIRTH OF LEGAL SPOUSE	DATE OF MARRIAGE

In the event there is no surviving legal spouse, list names and dates of birth of surviving children under age 18 on reverse side with a certified copy of the court document which appointed the legal guardian. The date of marriage and the date(s) of birth of the Survivor(s) have been verified by satisfactory evidence and the benefit authorized. A certified copy of the Death Certificate is attached.

Annually, Benefits resulting from the death of the employee are payable in accordance with the Army NAF Retirement Plan.

SECTION II - RETIREMENT FUND OPTIONS

CHECK ONE:

IN ACCORDANCE WITH AR 215-3

I REQUEST A REFUND OF MY CONTRIBUTIONS AND ACCUMULATED INTEREST IN FULL SATISFACTION OF ALL ANNUITY PAYABLE. I REQUEST MY CONTRIBUTIONS REMAIN ON DEPOSIT FOR A MAXIMUM OF 5 YEARS.

I REQUEST AN IMMEDIATE ANNUITY (NORMAL OR EARLY RETIREMENT)

I REQUEST A DEFERRED ANNUITY PAYABLE AT AGE 62.

I REQUEST DISABILITY RETIREMENT.

I REQUEST DISABILITY RETIREMENT DUE TO WORK RELATED INJURY/DISEASE.

I REQUEST SURVIVOR BENEFITS.

	SECTION III - EMPLOYEE'S OR SURVIVOR SIGNATURE
SIGNATURE OF EMPLOYEE/SURVIVOR	DATE
	SECTION IV - VERIFICATION

THE ABOVE INFORMATION HAS BEEN VERIFIED FROM THE EMPLOYEE'S PERSONNEL RECORDS AND DA FORM 3473 CODED 04 IS ATTACHED.

SECTION V - CPU MAILING ADDRESS

CPU

ADDRESS

CIVILIAN PERSONNEL OFFICER SIGNATURE	DATE
DA FORM 3715-R, NOV 85	EDITION OF FEB 85 IS OBSOLETE