Navigating the complexities of federal employment and retirement benefits demands a thorough understanding of the necessary documentation, one of which is the DS-5001 form, a pivotal document utilized by the U.S. Department of State. This form, officially titled "Application for Service Credit," serves multiple critical functions, primarily facilitating the acknowledgment and potential purchase of past federal civilian service periods during which retirement deductions were not withheld. What makes the DS-5001 stand out is its inclusivity of active military service, allowing those who served to potentially credit this time towards their civilian retirement perks without additional cost, pending submission of the appropriate official documents. Applicants are guided to recall and document their service history to the best of their ability, highlighting the form's dual focus: accuracy of historical employment data and the strategic planning of future benefits. The procedural advice is clear—complete the form in duplicate, submit without payment, and await verification before any financial commitment is made regarding service credit purchase. Moreover, the privacy act statement at the document's end underscores the sensitive handling of personal information, ensuring applicants that their Social Security Numbers and other personal data are solicited solely for benefits processing and are protected under strict confidentiality clauses. This careful balance of detailed instructions, benefits planning, and privacy considerations cements the DS-5001's role in the stewardship of federal employees' retirement readiness.
| Question | Answer |
|---|---|
| Form Name | Ds 5001 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 5001 fillable, 5001 fillable form, service credit form 5001, service credit 5001 form |
U.S. Department of State
APPLICATION FOR SERVICE CREDIT
1a. |
NAME (Last, First, Middle) |
2. LIST ALL OTHER NAMES YOU HAVE USED |
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1b. |
ADDRESS (Number and Street) |
3. |
DATE OF BIRTH |
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4. SOCIAL SECURITY NUMBER |
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(City. State, and ZIP Code) |
5. |
CURRENTLY EMPLOYED BY (Check One) |
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State |
Other Agency |
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6. List below in chronological order all federal civilian service from July 1, 1924 during which no Foreign Service retirement deductions were withheld from your salary.
DEPARTMENT OR AGENCY |
LOCATION OF EMPLOYMENT |
TITLE OF POSITION |
PERIODS OF SERVICE |
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(City and State) |
Beginning Date |
Ending Date |
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7. MILITARY RECORD - List below inclusive dates of active military service (see instructions on page 2 of this form). |
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ORGANIZATION |
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RANK |
ENTRANCE INTO ACTIVE DUTY |
DATE OF HONORABLE DISCHARGE |
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DATE |
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SIGNATURE OF APPLICANT |
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PLEASE READ INSTRUCTIONS ON PAGE 2 |
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Page 1 of 2 |
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INSTRUCTIONS TO APPLICANTS
1.The filing of this Form does not obligate the applicant to purchase any past service credit for which payment may be required. Under present laws and regulations, active military service creditable for retirement purposes without cost. The applicant is required to submit an official document reflecting inclusive dates of all active military service.
2.Complete the form to the best of your recollection. Do not communicate with the Departments or Agencies involved for verification of dates of employment.
3.Complete the form in duplicate and submit the original to:
a.U.S. Department of State Office of Retirement
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2401 E. Street, NW Room H620 |
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Washington, DC |
b. Human Resource Office if employed by another agency.
4.As soon as it is possible to verify the service claimed, the applicant will be informed of any payments required to obtain credit. DO NOT SEND ANY REMITTANCE WITH THIS APPLICATION.
PRIVACY ACT STATEMENT
PURPOSES AND USES
The primary purposes of the information solicited are to support enrollment, document an election not to enroll, and/or support a present or future claim for benefits under the Foreign Service Retirement Systems, the Federal Employees' Health Benefits Program, and/or the Federal Employees' Group Life Insurance Program. The information may be shared with a) other Federal agencies, b) national, state, county, municipal, or other publicly charitable or social security administration agencies, and c) private insurance carriers providing elected benefits. It will be shared only to the extent necessary to adjudicate a benefit or determine enrollment under the programs administered by such agencies.
EFFECTS OF NONDISCLOSURE
Provision of the information requested is voluntary; however, failure to supply all of the information may delay or prevent action on your, or your survivor's enrollment or claim for benefits.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW
Disclosure by you of your Social Security Number (SSN) is mandatory to obtain the services, benefits, or processes that you are seeking. Solicitation of the SSN by the U.S. Department of State is authorized under provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your federal career from the time of application through retirement. It will be used primarily to identify your records that you file with the Department of State and other federal agencies in connection with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former federal employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.
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