Form Cg 4700 – Fill Out and Use This PDF

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard

COAST GUARD, PHS & NOAA RETIRED PAY ACCOUNT WORKSHEET

AND SURVIVOR BENEFIT PLAN ELECTION

Privacy Act Statement

Authority: Collection of this information is authorized by: 10 U.S.C. Chapters 73 and 165; DOD Financial Management Regulation, Volume 7B, Chapters 14, 30, 49, and 54; and E.O. 9397.

Purpose: The Coast Guard Pay & Personnel Center will use this information to establish a retired pay account, including designation of beneficiaries for unpaid retired pay, election information under the Survivor Benefit Plan (SBP), and federal and state tax withholding elections.

Routine Uses: The information will be used by the Coast Guard Pay & Personnel Center to establish a retired pay account. The information may be shared with the Internal Revenue Service for tax purposes, and with the Department of Veterans Affairs in conjunction with administration of DVA compensation.

Disclosure: Disclosure of this information (including our beneficiary's SSN) is voluntary; however, failure to furnish the requested information will result in delays in initiating retired pay.

Any “collection of information” as defined in the Paperwork Reduction Act of 1995 (codified at 44 U.S.C. 3501 et seq) on this form has not been approved by the Director of the Office of Management and Budget (OMB) and does not display a valid control number assigned by the Director. Therefore, no person shall be subject to any penalty for failing to comply with any such collection of information.

SECTION I: IDENTIFICATION AND ADDRESS (complete all sections, if not applicable enter N/A)

1. YOUR APPROVED RETIREMENT DATE 2. Retiring from the following Service (select one):

9.Please provide your Home & Business (if applicable) email addresses if you would you like PPC (RAS) to contact you via e­mail in case telephone contact cannot be established:

SECTION II: PAY DELIVERY (See instructions for proper completion)

Public Law 103­356 makes direct deposit mandatory

17. Address­City, State, and ZIP Code:

SECTION III: TAX WITHHOLDING INFORMATION (use instructions for IRS Form W­4 and State Tax form to complete)

FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT

SECTION IV: DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY

I hereby designate the following beneficiary(ies) to receive retired pay due and payable at my death. I am aware that under the provisions of 10 U.S.C. 2771 and 4 CFR Part 34, this designation will remain in effect unless canceled or changed by me.

SECTION V: CERTIFICATION DATA FOR PAYMENT OF RETIRED PERSONNEL (must be completed)

connection with any matter endangering the National Security, or defense of the United States or any relationship I have or have not had with a foreign government (5 U.S.C. 8314).

material fact in an employment application for a civilian or military office or position in or under the Legislative, Executive, or the Judicial branch of Government of the United States or the government of the District of Columbia(5 U.S.C. 8315).

foreign government nor have I made application for such employment and I have not negotiated for such employment. I understand that before I accept such employment I must obtain advance approval from Commandant (CG­1222) (for CG retirees) or NOAA or PHS HQs (for NOAA or PHS retirees) and the Department of State.

or other Government agency nor have I made application for such benefits.

If you are drawing a VA or civil service pension, retired pay, or disability compensation, or have made application therefore, please provide the name and address of the agency and the monthly amount received (if any) in the space below.

FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT

SECTION VI: SURVIVOR BENEFIT PLAN (SBP) ELECTION (Complete all blocks)

33.Level of coverage (do not complete if 32d or 32g was elected above)

a. I did NOT elect the Career Status Bonus and REDUX. I elect SBP coverage as follows (choose one):

I elect coverage based on full gross retired pay.

I elect coverage with a reduced base amount of $___________________ ($300 minimum base amount).

b. I DID elect the Career Status Bonus and REDUX. I elect SBP coverage as follows (choose one):

I elect coverage based on the amount of retired pay I would have received had I NOT elected the Career Status Bonus.

I elect coverage based on my current gross retired pay.

I understand this represents a reduced base amount and requires spousal concurrence.

I elect coverage with a reduced base amount of $___________________ ($300 minimum base amount). This requires spousal concurrence.

*BLOCK 42 NOTE: Disabled Child ­ If yes, provide a current physician's statement dated within 90 days of the date of retirement describing the medical condition and whether it is temporary or permanent and why the condition is considered incapacitating (e.g. the dependent is unable to take care of basic activities of daily living).

SECTION VII: SBP SPOUSAL CONCURRENCE

(Required when member is married and elects child(ren) only coverage, does not elect full spouse coverage, or declines coverage)

I hereby concur with the Survivor Benefit Plan election made by my spouse. I have received information that explains the options available and the effects of those options. I know that retired pay stops on the date the retiree dies. I understand and acknowledge that I am waiving my statutory right to receive my own annuity (or electing to receive a reduced annuity) for life if my spouse precedes me in death. I also understand and acknowledge that this waiver of my statutory right to receive an annuity (or my election to receive a reduced annuity) is irrevocable. I have signed this statement of my free will.

Former Spouse (Complete ONLY if 32e or 32f was elected above)

Note: Under the law, you “first became a member” of the Uniformed Services on the date first enlisted, inducted, or appointed. For non­prior service Academy cadets and OCS graduates, it is the date you took the oath of office for entrance into the Academy (for Academy cadets, this is not the date your creditable service for retirement begins) or OCS. For enlisted members who enlisted under the Delayed Entry Program (DEP), it is the date you signed up for the DEP.

62. PRIOR SERVICE BREAKDOWN (FOR COAST GUARD ACTIVE DUTY, PHS, OR NOAA PERSONNEL ONLY)

SECTION X: MEMBER'S CERTIFICATION (member and witness signature and date (must sign on same date) required for start of retired pay)

Under penalties of perjury, I certify that the number of withholding exemptions claimed does not exceed the number to which I am entitled, and that all statements on this form are made with full knowledge of the penalties for making false statements. (18 U.S.C. 287 and 1001 provide for a penalty of not more than $10,000 fine, or 5 years in prison, or both). Also, I have been counseled that I can terminate SBP participation, with my spouse's written concurrence, within one year after the second anniversary of commencement of retired pay. However, if I exercise my option to terminate SBP, future participation is barred.

FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT