Form Ri 92 19 – Fill Out and Use This PDF

Item 2: List other names under which you have been employed in the Federal government (such as a maiden name).

Item 4: Enter the address to which correspondence should be mailed. Do not enter the bank address where your payments will be deposited here; complete Section H of this application.

Item 2: Show the agency where you performed your last Federal service. Give the bureau and/or division as well as the name of the agency and include its location (city, state).

Item 3: List all Federal civilian service that you have performed. Give the bureau and/or division as well as the name of the agency, along with the agency's location and the beginning and ending dates of the service.

Item 1: Indicate whether you have performed active duty that terminated under honorable conditions in the armed services or other uniformed services of the United States.

Item 2: Persons who performed active military service after December 31, 1956, must have paid a deposit to receive credit under the Federal Employees Retirement System (FERS) for their military service. If you did not pay your deposit while you were still a Federal employee, you cannot pay it now.

If you have performed active, honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definition), complete 3a-d and attach a copy of your discharge certificate or other certificate of active military service (if available).

Item 3: If you have applied for or have ever received workers' compensation from the Office of Workers' Compensation Programs (OWCP), U.S. Department of Labor, because of a job-related illness or injury, check the “Yes” box and furnish your claim number(s), type(s) of benefits, and date(s) of benefits in 3a, 3b and 3c.

Are you married? If separated from your spouse, but the marriage has not ended by divorce or annulment, answer "Yes."

Read the attached instructions before making this election. Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested.

Consider your election carefully. No change will be permitted after your annuity is granted except as explained in the pamphlet Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement System, RI 92-19A.

If you are currently married and you do not elect maximum survivor benefits the law requires that your spouse consent to your election; therefore, you must complete Schedule A and attach it to this application.

1. I choose a reduced annuity with maximum survivor annuity for my spouse named in Section E. If you are married at retirement you will automatically receive this type of annuity unless your spouse consents to your election not to provide maximum survivor benefits. If you receive this annuity, your annuity will be reduced by 10%. The survivor's annuity upon your death will be 50% of your unreduced annuity.

2. I choose a reduced annuity with a partial survivor annuity for my spouse named in Section E. If you choose this option, your annuity will be reduced by 5%. Upon your death, your spouse's annuity will be 25% of your unreduced annuity.

3. I choose an annuity payable only during my lifetime.

4. I choose a reduced annuity with survivor annuity for the person who has an insurable interest in me. You must be healthy and willing to provide medical evidence if you choose this type of annuity.

5. I choose a reduced annuity with survivor annuity for my former spouse(s) as follows: You must attach: 1. Certified copies of divorce decrees for all former spouses for whom you elect to provide survivor annuity. 2. If you are married, attach a completed Schedule A (Spouse's Consent to Survivor Election).

Complete Section G by providing the names and dates of birth of your unmarried dependent children under the age of 22. Also list any child over the age of 22 who is incapable of self-support because of mental or physical disability incurred before the age of 18. Check the box headed “disabled” by the name of each child to whom this applies.

Complete in all cases.

Item 2: You may obtain your Financial Institution Routing Number by calling your bank, credit union, or savings institution. This number is very important.

If you prefer, you may attach a cancelled personal check that shows the information requested instead of filling in the requested financial institution information.

By signing you certify that all statements made in this application are true to the best of your knowledge and that no evidence necessary to the settlement of this claim is withheld.

Any intentionally false statement or willfully misleading statement or response you provide in this application is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years or both (18 U.S.C. 1001) (checked November 2, 2026).

Instructions - Complete this schedule if you are married and do not elect a reduced annuity to provide a full current spouse survivor annuity.

In Schedule A, Part 2 must be completed in the presence of a Notary Public or other person authorized to administer oaths.

The Notary Public must complete Part 3.

If you have at least 10 years of creditable service (5 of which must be civilian) which will be used to compute your benefit, then you must complete one of Schedules B and C.

Do not complete either of these schedules if you have less than 10 years of service.

Complete Schedule B if you had attained the Minimum Retirement Age (MRA) when you left Federal service and had at least 10 years of creditable service.

Complete Schedule C if you had not yet attained the MRA when you left Federal service, but you did have at least 10 years of creditable service.

Send your completed application approximately 60 days before you want your benefits to begin.

Send your completed application to Office of Personnel Management, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045.