Sf 3107 2 PDF Details

Sf 3107 2 form is a tax form used to report certain information about the sale or exchange of property. The form is used to report the amount of gain or loss on the sale, as well as other information about the transaction. Updated versions of Sf 3107 2 form may be released periodically, so it's important to ensure that you're using the most up-to-date version. In addition, be sure to consult with a tax professional if you have any questions about how to complete this form. By understanding and correctly completing Sf 3107 2 form, taxpayers can avoid incurring unnecessary penalties from the IRS.

In the table, there is some good information relating to the sf 3107 2. You'll have the approximated time it'd require you to prepare the form plus some extra details.

QuestionAnswer
Form NameSf 3107 2
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesstandard form 3107 2, sf 3107 2, sfform3107 2, 3107 2

Form Preview Example

Application for Immediate Retirement

Federal Employees Retirement System

Federal Employees Retirement System

This application is for you if you are a Federal employee covered by the Federal Employees Retirement System (FERS) and you wish to apply for retirement with an immediate annuity. You should use this application if you want to apply for an annuity which will begin within 30 days of your separation from Federal service.

Do not use this application to apply for a deferred annuity. A deferred annuity begins more than 30 days after the date of final separation. If you want to apply for a deferred annuity, call the Office of Personnel Management (OPM) on 1-888-767-6738 (TTY: 1-855-887-4957) to request an RI 92-19, FERS Application for Deferred or Postponed Retirement. If you prefer, you can write to us at Office of Personnel Management, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045, or email us at retire@opm.gov. You can also find this form on our website at www.opm.gov/forms/Retirement-and-Insurance-Forms.

You should have received an informational pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System, with this application. If you did not receive the pamphlet you should get a copy from your employing agency or from our website at www.opm.gov/retirement-services/publications-forms/pamphlets/#url=FERS.

Retirement benefits and retirement processing are complicated. Read the information in the pamphlet carefully. When you decide to retire, give your agency advance notice so it can be sure your records are complete and it can carry out its responsibilities in processing the paperwork associated with your retirement.

Give your completed application to the personnel office of your employing agency. They will forward your application to your agency payroll office and then to the Office of Personnel Management for processing. If you have any questions, ask your employing office for assistance.

You must apply separately for any benefits payable from the Thrift Savings Plan and the Social Security Administration.

If your address changes after your application has been forwarded to the Office of Personnel Management, call us on 1-888-767-6738 (TTY: 1-855-887-4957). If you prefer, you can write to us at the address above. If you have received your claim number, please refer to it. If you have not received your claim number we'll need your name, date of birth and social security number.

Instructions for Completing Application

Type or print clearly. If you need more space in any section, use

Item 4: Indicate whether or not you have performed active duty

a plain piece of paper with your name, date of birth, and Social

that terminated under honorable conditions in the

Security Number written at the top. If you do not know an

armed services or other uniformed services of the

answer write "unknown." If you are unsure of information (for

United States including the following:

example, if you do not know an exact date), answer to the best

a.

Army, Navy, Marine Corps, Air Force or Coast

of your ability, followed by a question mark (?).

 

Guard of United States;

 

 

The following additional information should help you to answer

b.

Regular Corps or Reserved Corps of the Public

those questions on the application which are not entirely

 

Health Service after June 30, 1960;

self-explanatory.

c.

Commissioned Officer of the National Oceanic

 

Section A - Identifying Information

 

and Atmospheric Administration after June 30,

Item 2: List other names under which you have been employed

 

1961 or a predecessor entity in function;

in the Federal government (such as a maiden name).

d.

Cadet at the U.S. Military Academy, U.S. Air

This will help us to locate and identify records

maintained under these names.

 

Force Academy, U.S. Coast Guard Academy, or

 

 

midshipman at the U.S. Naval Academy.

Item 3: Enter the address to which correspondence should be

e.

Excluding the National Guard, active service in the

mailed. Do not enter the bank address where your

payments will be deposited here; see Section H of the

 

reserve components of the uniformed services,

application form for payment information.

 

including active duty for training, is military

Item 4: Give a telephone number where you can be reached

 

service. Service as a National Guard member does

 

not meet the definition of military service for

after you retire and the best time to reach you during

 

purposes of civil service retirement, except when

business hours.

 

the member is ordered to active duty in the service

Section B - Federal Service

 

of the United States or performs full-time National

 

Guard duty (as such term is defined in section

Item 2: Enter the date of final separation for retirement. (Leave

 

101(d) of title 10) if the National Guard duty

 

interrupts creditable civilian service under

blank if applying for disability retirement and not

 

 

subchapter I of chapter 84 of title 5, and is

separated.) Please note that if you are currently serving

 

 

followed by reemployment in accordance with

in more than one appointive or elective position in the

 

 

chapter 43 of title 38 that occurs on or after August

Federal Government, you must separate from all such

 

 

1, 1990.

positions before you can qualify for an immediate

 

retirement.

 

 

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-108

Previous editions are not usable.

Standard Form 3107

Revised May 2014

If you have performed such service, complete and attach Schedule A, furnishing the requested information for each period of active duty.

To receive FERS credit for military service performed on or after January 1, 1957, you must pay a deposit. The amount of the deposit is:

For service performed through 12/31/98 (3% of your military basic pay).

For service performed from 1/1/99 through 12/31/99 (3.25% of your military basic pay).

For service performed from 1/1/00 through 12/31/00 (3.4% of your military basic pay).

For service performed from 1/1/01 to the present (3% of your military basic pay).

You must pay the deposit to your agency while you are still employed. You may not pay OPM after you retire.

If you are entitled to have part of your retirement computed under CSRS rules, military service performed prior to your transfer to FERS comes under CSRS deposit rules. These rules are as follows:

The CSRS deposit is 7 percent of your military basic pay.

If you were first employed in a civilian position subject to CSRS coverage before October 1, 1982, you do not pay the deposit and you are eligible for a Social Security benefit at age 62, the CSRS part of your annuity will be recomputed at age 62 to delete credit for the post-1956 military service.

If you were first employed in a civilian position subject to CSRS coverage on or after October 1, 1982, you will not receive any credit for post-1956 military service if you do not make the deposit for it.

CSRS military service deposits must also be paid to your agency while you are still employed.

The law gives an alternate method to compute the military deposit if an employee served on active duty, and such service interrupted creditable civilian service under subchapter I of chapter 84 of title 5, and was followed by reemployment in accordance with chapter 43 of title 38 that occurs on or after August 1, 1990. The employee pays no more than the amount of retirement contributions that would have been withheld from basic pay during civilian service if the employee had not performed the period of military service.

Item 5: If you are receiving, or have applied for, military retired pay or benefits from the Department of Veterans Affairs in lieu of military retired pay, answer "yes" to Item 5, then complete and attach Schedule B-Military Retired Pay. (Note: Military retired pay includes disability retired pay and reserve retainer pay.)

This information is needed to assure correct credit for military service. With limited exceptions, you must waive your military retired pay to receive credit for your military service in your FERS annuity.

You may receive credit in your FERS annuity for your military service without waiving your military retired pay if you are entitled to military retired pay awarded for:

reserve service under Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10); or

a disability incurred in combat with an enemy of the United States; or caused by an instrumentality of war in the line of duty during a period of war as defined by Section 1101 of title 38.

Attach a copy of your retirement order from your military service to this application. If applicable, also attach a copy of your military service's determination that your military disability retirement was service connected and incurred in combat as described, or caused by an instrumentality of war as described. Only your military service branch can make this determination; the Department of Veterans Affairs cannot make this determination. If you do not have verification of the type and conditions of your military retirement, you should get the verification from the retirement service organization of your military service before you retire from your civilian position.

If you are waiving military retired pay for FERS retirement purposes, your agency can help you prepare your request for waiver. Attaching a copy of your waiver request and the military finance center's acknowledgment (if available) to your application may help us to process your claim more quickly. (Even if you have already waived your military retired pay to receive benefits from the Department of Veterans Affairs, you also need to file a waiver for FERS.)

Obtain counseling from the military before waiving military retired pay for FERS retirement if you receive or may receive Combat Related Special Compensation (CRSC) or concurrent receipt of military retired pay and veterans compensation.

Reminder: Even if you have waived military retired pay or qualify for one of the exceptions to waiver, you must pay a military deposit for your military service performed after 1956 to receive credit for the service in your FERS annuity, and the military deposit must be paid to your employing agency before you retire.

Section C - Marital Information

Item 2: Indicate whether you have a living former spouse to whom a court order awards a survivor annuity or a portion of your retirement benefits based on your Federal employment. If you answer "yes," you must submit a certified copy of the court order and any attachments or amendments.

Section D - Annuity Election

(See pages 13-20 of SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System.)

Read the information about survivor benefits found in the pamphlet, Applying for Immediate Retirement Under FERS, before completing Section D.

Survivor elections terminate upon the death of the person elected. An election of a survivor annuity for a current spouse in box 1 or 2 also terminates upon a divorce from that spouse. An election of a survivor annuity for a former spouse in box 5 also terminates if that former spouse remarries before age 55, unless the annuitant and the former spouse were married for 30 years or more. You must notify us when one of those events terminating a survivor election occurs. Also notify us if a former spouse who is entitled to a survivor annuity under a court order acceptable for processing becomes ineligible for the former spouse annuity because of a reason specified in the court order or because of a remarriage prior to age 55.

2

Standard Form 3107

Revised May 2014

Please note that, in accordance with the law, both a survivor

You may elect to provide a survivor annuity for more

annuity election made at retirement and a survivor annuity

than one former spouse. The total of the survivor

election made before a divorce, terminate upon death or

annuities must equal either 25% or 50% of your

divorce and the annuitant must make a new election (reelection)

unreduced annuity.

within 2 years after the terminating event to provide a survivor

If you are married, you must have your spouse's consent

annuity for a spouse acquired after retirement or for a former

spouse. Continuing a survivor reduction, by itself, is not

to choose this option, because any benefit elected for a

effective to reelect a survivor annuity for a spouse married after

former spouse limits what can be elected for your

retirement or for a former spouse.

 

 

current spouse. (Complete and attach SF 3107-2,

Box 4: If you initial Box 4, a person selected by you,

Spouse's Consent to Survivor Election, to your

application.) The maximum combined survivor benefits

 

who has an insurable interest in you, will receive

 

that can be elected for your current and former spouse(s)

 

a survivor annuity upon your death. Insurable

 

is 50% of your benefit.

 

interest exists if the person named may reasonably

 

 

 

expect to derive financial benefit from your

Section E - Insurance Information

 

continued life. A disabled child or a former

 

Item 1b: Indicate whether there is a court order or

 

spouse are persons who might have an insurable

 

interest in you.

 

 

administrative order currently in effect that

 

If you choose an insurable interest survivor

requires you to provide health benefits coverage

 

for your child(ren). If you answer "yes", you must

 

annuity, the survivor annuity will be 55 percent of

submit a copy of the court order or administrative

 

your annuity after your annuity has been reduced

order.

 

to provide this benefit. The table below shows the

 

 

reduction percentages.

 

 

Section F - Other Claim Information

 

Any employee who is not retiring for disability

 

Item 1: If you have applied for, or have ever received, workers'

 

and who can prove good health may elect a

 

compensation from the Office of Workers'

 

reduced annuity to provide a survivor annuity for

 

Compensation Programs, U.S. Department of Labor,

 

a person having an insurable interest in the

 

because of a job-related illness or injury, check the

 

retiree.

 

 

 

 

 

"yes" box and complete Schedule C.

 

 

 

 

 

You may elect this insurable interest survivor annuity

In Schedule C you should provide the following

 

in addition to a regular survivor annuity for a current or

 

information:

 

former spouse. If you elect an insurable interest annuity

 

 

 

for your current spouse, you must both jointly waive

1. If you are receiving or have received

 

the current spouse annuity. Generally, an insurable

compensation, enter your compensation claim

 

interest annuity cannot be cancelled. However, if you

number(s), the beginning and ending dates of each

 

elect an insurable interest annuity for your current

period for which compensation was paid, and

 

spouse because a former spouse is entitled to the

whether the benefits were a scheduled award,

 

regular survivor annuity (under a court order acceptable

disability or other type of compensation.

 

for processing or based on your election of that

2. If you have applied for, but are not receiving

 

survivor benefit for the former spouse), you can

 

convert the insurable interest election for your current

benefits, indicate whether your claim is pending

 

spouse to a current spouse annuity within two (2) years

or has been denied and the claim numbers

 

of the former spouse losing entitlement to the regular

applicable.

 

survivor annuity.

 

 

3. Indicate whether you agree to notify us if the

 

If you choose an insurable interest annuity, the amount

 

status of your workers' compensation claim

 

of the reduction in your annuity will depend upon the

changes and whether or not you authorize the

 

difference between your age and the age of the person

Office of Personnel Management and/or the

 

named as survivor annuitant, as shown in the table

Office of Workers' Compensation Programs to

 

below.

 

 

collect any overpayment if we find that you

 

Age of the Person Named

Reduction

 

were paid, but not eligible for, both compensation

 

in Relation to That of

in Annuity

 

and annuity benefits covering the same period of

 

 

time. Without this authorization from you, we

 

Retiring Employee

of Retiring

 

 

 

will not pay your annuity until we can confirm

 

 

Employee

 

 

 

 

that OWCP is not paying you compensation.

 

Older, same age, or less than 5 years younger

10%

 

The information requested regarding benefits from

 

 

 

 

the Office of Workers' Compensation Programs is

 

5 but less than 10 years younger

15%

 

 

 

needed because the law prohibits the dual compen-

 

10 but less than 15 years younger

20%

 

sation which would exist if you received both a

 

 

FERS annuity and compensation for total or partial

 

 

 

 

 

 

 

 

disability under the Federal Employees' Compen-

 

15 but less than 20 years younger

25%

 

 

 

 

 

sation Act.

 

20 but less than 25 years younger

30%

 

 

 

Section G - Information About Children

 

 

 

 

 

25 but less than 30 years younger

35%

 

 

 

Complete Section G by providing the names and dates of birth

 

 

 

 

 

30 or more years younger

40%

 

of your unmarried dependent children under the age of 22. Also

 

 

 

 

list any child who is over age 22 and incapable of self-support

Box 5: If you initial box 5, your former spouse(s) will receive a

because of mental or physical disability incurred before age 18.

Check the box headed "disabled" by the name of each child to

 

survivor annuity upon your death. The maximum

 

whom this applies. Information about your children in your

 

survivor annuity payable to your former spouse(s) is

 

annuity claim file may help to expedite the processing of claims

 

50% of your unreduced annuity. Your annuity will be

 

for survivor benefits in the event of your death.

 

reduced 5% or 10% according to the total benefit you

 

 

 

want to provide.

3

Standard Form 3107

 

 

Revised May 2014

Section H - Payment Instructions

Complete in all cases. The US Department of the Treasury pays all Federal benefit payments electronically. Most Federal payments are paid by Direct Deposit into a savings or checking account at a financial institution. If you do not have a bank account, or prefer not to have your annuity payments deposited directly to your bank account, you can choose a Direct Express debit card. If you choose this option, your annuity payment will be automatically deposited to the Direct Express card on the payment date. To obtain a debit card, go to www.godirect.org or call 1-800-333-1795. If your payments are not electronically deposited to your account and you do not have a Direct Express card, you must contact the Department of the Treasury at 1-800-333-1795.

You cannot receive your annuity payments by direct deposit or the Direct Express debit card program if your permanent payment address is outside the United States in a country where these programs are not available.

Section I - Applicant's Certification

Be sure to sign (do not print) and date your application after reviewing the warning.

Privacy Act Statement

Solicitation of this information is authorized by the Federal Employees Retirement law, (Chapter 84, title 5, U.S. Code), the Federal Employees Group Life Insurance law (Chapter 87, title 5, U.S. Code) and the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a unique identifiable claim file. The information may be shared and is subject to verification via paper, electronic media, or through the use of computer matching programs with national, state, local or other charitable or social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination or continuation of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number. The Government may use your number in collecting and reporting amounts that you owe the Government. Failure to furnish the requested information may delay or prevent action on your application. Information you provide about your unmarried dependent children may be used to expedite their claims after you die; however, your failure to supply such information will not affect any future rights they may have to benefits.

4

Standard Form 3107

Revised May 2014

Federal Employees Retirement System

Application for Immediate Retirement

Federal Employees Retirement System

See Privacy Act

Information on

Instruction Sheet

Section A - Identifying Information

1.

Name (last, first, middle)

 

 

 

 

2. List all other names you have used

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Address (number, street, city, state, ZIP code)

4a.

Daytime telephone # after retirement (including area

4b.

Best time to reach you

 

 

 

 

 

 

 

 

code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4c.

Home email address

4d.

FAX Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Date of birth (mm/dd/yyyy)

6.

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Are you a citizen of the United States of America?

8.

Is this an application for disability retirement?

 

 

 

 

 

 

Yes

 

No

 

Yes (Ask your employing office about other documents you must submit)

 

No

 

 

 

 

 

Section B - Federal Service

 

 

 

 

 

 

 

1.

Department or agency from which you are retiring (include bureau or division, address and ZIP code)

2.

Date of final separation (mm/dd/yyyy)

 

 

 

 

 

 

 

 

3.

Title of position from which you are

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

retiring

 

 

 

 

 

 

 

 

 

 

3a.

Your pay plan and occupational series

 

 

 

 

 

 

 

 

4.Have you performed active honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definitions)?

Yes (Complete Schedule A and attach it to this form)

No

5.Are you receiving or have you applied for military retired pay? (Note: If you later become entitled to military retired pay you must notify OPM.)

Yes (Complete Schedule B and attach it to this form)

 

No

Section C - Marital Information (All applicants must complete questions 1 and 2 below.)

1.Are you married now? (A marriage exists until ended by death, divorce, or annulment.)

 

 

Yes (Complete items 1a - 1f and attach a copy of your marriage certificate)

 

No (Go to item 2)

1a.

Spouse's name (last, first, middle)

 

1b.

Spouse's date of birth (mm/dd/yyyy)

1c. Spouse's Social Security Number

 

 

 

 

 

 

1d.

Place of marriage (city, state)

1e. Date of marriage (mm/dd/yyyy)

1f.

Marriage performed by:

Clergyman or Justice of Peace

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (explain):

2.Do you have a living former spouse(s) to whom a court order gives a survivor annuity or a portion of your retirement benefits based on your Federal employment?

Yes (Attach a certified copy of the court order[s] and any amendments.)

 

No

Section D - Annuity Election

Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested. Read the pamphlet SF 3113, Applying for Immediate Retirement under FERS and the explanations below and consider your election carefully. No change will be permitted after your annuity is granted except as explained in the pamphlet. If you are married at retirement, the law provides an annuity with full survivor benefits for your spouse unless your spouse consents to your election not to provide maximum survivor benefits.

Your election to provide a survivor annuity for a current spouse terminates upon the death of that spouse or if the marriage ends due to divorce or annulment. You are required to make a new election (reelect) within 2 years of the terminating event if you wish to reelect a survivor annuity for a former spouse or within 2 years of a post-retirement marriage to elect a survivor annuity for a spouse acquired after retirement. Continuing a survivor reduction by itself, is not effective to reelect a survivor annuity for a spouse married after retirement or for a former spouse.

If you want to elect a partial survivor annuity for your current spouse and a survivor benefit for a former spouse, you should complete options 2 and 5 below. The total of the survivor annuities elected cannot exceed 50 percent. An election of an insurable interest survivor in option 4 is not included when determining the 50 percent maximum.

1.

Initials

I choose a reduced annuity with maximum survivor annuity for my spouse named in Section C. If you are married at retirement, you will 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%. Your spouse's annuity upon your death will be 50% of your unreduced earned annuity.

2.

Initials

I choose a reduced annuity with a partial survivor annuity for my spouse named in Section C. 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 earned annuity. You must have your spouse's consent to choose this option. Complete form SF 3107-2, Spouse's Consent to Survivor Election, and attach it to your application.

3.

Initials

I choose an annuity payable only during my lifetime. If you are married at retirement, you cannot choose this type of annuity without your spouse's consent. No survivor annuity will be paid to your spouse after your death if he or she consents to this election and any health benefits will cease. In addition, your spouse will not be eligible to enroll in the Federal Long Term Care Insurance Program, if he/she is not enrolled at the time of your death. If you are married and elect this, complete form SF 3107-2, Spouse's Consent to Survivor Election, and attach it to your application.

 

3107-108

Standard Form 3107

CSRS/FERS Handbook for Personnel and Payroll Offices

Previous editions are not usable.

Revised May 2014

Section E - Insurance Information

4.

Initials

I choose a reduced annuity with survivor annuity for the person named below who has an insurable interest in me. You must be healthy and willing to provide medical evidence if you choose this type of annuity. (Disability annuitants are not eligible to choose this type of annuity.) If you are married and elect this option for your spouse, complete SF 3107-2, Spouse's Consent to Survivor Election and attach it to your application.

Name of person with insurable interest

 

Relationship to you

Date of birth (mm/dd/yyyy)

Social Security Number

 

 

 

 

 

 

5.

Initials

I choose a reduced annuity with survivor annuity for my former spouse(s) as follows: You must attach: (1) Copies of divorce

 

 

decrees for all former spouses for whom you elect to provide a survivor annuity. (2) If you are married, attach a completed

 

 

 

 

SF 3107-2,

Spouse's Consent to Survivor Election. You cannot choose this option and provide a maximum survivor annuity for

your spouse (Box 1). Your election to provide a survivor annuity for a former spouse terminates upon the death of that spouse or the remarriage of your former spouse before age 55.

Name and address of former spouse

 

Date of marriage

Date of divorce

 

 

 

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

 

Survivor annuity equal

 

 

 

 

 

to _______________%

 

 

 

Date of birth

Social Security Number

 

 

 

(mm/dd/yyyy)

 

 

 

of my annuity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and address of former spouse

 

Date of marriage

Date of divorce

 

 

 

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

 

Survivor annuity equal

 

 

 

 

 

to _______________%

 

 

 

Date of birth

Social Security Number

 

 

 

(mm/dd/yyyy)

 

 

 

of my annuity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total (either 25% or 50% of your unreduced annuity)

 

_______________%

 

 

 

 

1a.

2.

See the pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System, for information.

Are you eligible to continue Federal Employees Health Benefits coverage as a

1b. Is there a court order or administrative order currently in effect that requires

 

retiree?

 

 

 

you to provide health benefits coverage for your child(ren)?

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Yes (Attach a copy of the court/administrative order)

No

Are you eligible to continue Federal Employee's Group Life Insurance coverage as a retiree?

3.

Yes

Are you enrolled in the Federal Dental and Vision Insurance Program (FEDVIP)?

No

4.

Yes Your coverage will automatically continue into retirement as long as you continue to pay applicable premiums. Until work on your annuity is completed, you may receive bills from BENEFEDS. You must pay these bills in order to keep your FEDVIP coverage. After work on your annuity is completed, BENEFEDS will automatically begin deducting from your annuity to pay future premiums. If you have questions, please contact BENEFEDS at 1-877-888-3337.

No If you retire on an immediate annuity, you can enroll in FEDVIP during any Federal Benefits Open Season.

Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?

Yes You will automatically continue your coverage into retirement, as long as you continue to pay applicable premiums. If you are currently paying FLTCIP premiums by agency payroll deduction, you must arrange to pay premiums another way, either by deductions from your annuity, through automatic bank debit or direct bill. Please call LTC Partners at 1-800-LTC-FEDS (1-800-582-3337) to make these arrangements.

No

Section F - Other Claim Information

1.Have you applied for, are you receiving, or have you ever received workers' compensation from the Department of Labor because of a job-related illness or injury?

 

 

Yes (Complete Schedule C and attach it to this form)

 

No

 

 

2.

Have you previously filed any application under the Civil Service Retirement System or Federal Employees Retirement System (for retirement, refund, deposit or redeposit,

 

or voluntary contributions)?

 

 

Yes (Complete items 2a and 2b below.)

 

No

 

 

 

 

 

 

 

 

 

 

 

2a.

Type of application

 

Refund

 

Deposit or redeposit

2b.

Claim number(s)

 

 

Retirement

 

Return of excess deductions

 

Voluntary contributions

 

 

Section G (Optional) - Information About Your Unmarried Dependent Children

1.Dependent child's name

(first, middle, last)

2.Date of birth (mm/dd/yyyy)

3.Disabled 1.

Dependent child's name

()

(first, middle, last)

2.Date of birth (mm/dd/yyyy)

3.Disabled

()

 

3107-107

CSRS/FERS Handbook for Personnel and Payroll Offices

Previous editions are not usable.

Standard Form 3107 Revised May 2014

Section H - Payment Instructions

1.Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department of the Treasury. See the instructions for Section H of this application and SF 3113 (Applying for Immediate Retirement Under the Federal Employees Retirement System) for additional information. This does not apply to you if your permanent payment address is outside the United States in a country not accessible via direct deposit.

Please select one of the following:

Please send my annuity payments directly to my checking or savings account. (Go to item 2) Please send my annuity payments to my Direct Express debit card. (Go to item 3a)

My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to item 3a)

2a.

Financial Institution Routing Number

 

 

You may obtain this number by calling your bank, credit union, or savings institution.

 

 

 

 

 

 

This number is very important. We cannot pay by direct deposit without it.

2b.

Checking or Savings Account Number

2c. What kind of account is this?

2d. Telephone number of your Financial Institution (including area code)

 

 

 

 

 

 

Checking

 

 

Savings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2e.

Name and address of Financial Institution

 

 

 

 

 

 

 

Special Note: If you prefer, you may attach a cancelled personal check that

 

 

 

 

 

 

 

 

 

 

 

shows the information requested above, instead of filling in the requested

 

 

 

 

 

 

 

 

 

 

 

financial institution information. If you attach your personal check, it is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

especially important that you contact your bank, credit union, or savings

 

 

 

 

 

 

 

 

 

 

 

institution to confirm that the information on the check is the correct

 

 

 

 

 

 

 

 

 

 

 

information for direct deposit. (Some institutions, especially credit unions,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

use different routing numbers on checks.) We can then use this information

 

 

 

 

 

 

 

 

 

 

 

to start paying you by direct deposit.

3a.

Do you want Federal income tax withheld from your annuity payments?

 

3b. Do you want to have Federal Income Tax withheld at the rate currently being

 

 

 

 

 

 

 

 

 

 

 

withheld from your salary?

 

 

 

 

 

 

 

 

 

 

 

 

Yes (Attach copy of W-4 form on file with your employing agency.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes (Go to item 3b)

 

No (Go to Section I)

 

 

 

No (Attach new W-4 form, otherwise withholding will be at rate for

 

 

 

 

 

 

 

 

 

 

 

 

married with 3 exemptions.)

 

 

 

 

 

 

 

 

 

 

 

Section I - Applicant's Certification

 

 

 

 

Warning

Any intentionally false statement in this application or willful misrepresentation relative thereto 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)

I hereby certify that all statements made in this application are true to the best of my knowledge and belief.

Signature (Do not print)

Date (mm/dd/yyyy)

 

 

Applicant's Checklist

This checklist is provided to help you be certain you have attached all necessary documentation and to help your employing office be certain it forwards all of your retirement documentation to the Office of Personnel Management.

1.Military Service - If you answered "yes" to Section B, Item 4, did you attach Schedule A?

2.Military Service - If you completed Schedule A, did you attach a copy of your discharge certificate or other certificate of active military service?

3.Military Retired Pay - If you answered "yes" to Section B, Item 5, did you attach Schedule B?

4.Military Retired Pay - If you completed Schedule B and answered "yes" to Item b or c, did you attach a copy of the notice of award or other documentation of the type of military retired pay you are receiving?

5.Military Retired Pay - If you completed Schedule B and answered "yes" to item d, did you attach a copy of your request for waiver and a copy of the military finance office's acknowledgment or approval of your request for waiver (if applicable)?

6.Survivor Election - If you are married and did not initial box 1 of Section D, did you attach SF 3107-2, Spouse's Consent to Survivor Election?

7.Life Insurance - If you answered "yes" to Section E, item 2, did you attach SF 2818, Continuation of Life Insurance Coverage As an Annuitant or Compensationer?

8.OWCP - If you answered "yes" to Section F, item 1, did you attach Schedule C?

9.Tax - If you want to elect a Federal Income Tax withholding rate, did you attach a W-4 form?

10.Court or Administrative Order(s) - If you answered "yes" to Section C, item 2 and/or "yes" to Section E, Item 1b, did you attach a copy of the order(s)?

Yes

No

Not

Applicable

 

3107-108

Standard Form 3107

CSRS/FERS Handbook for Personnel and Payroll Offices

Previous editions are not usable.

Revised May 2014

Schedules A, B and C

1.Name (last, first, middle)

2.Date of birth (mm/dd/yyyy)

3.Social Security Number

Schedule A - Military Service Information

1.If you have performed active honorable service in the United States Armed Services or other uniformed services, complete 1a - d below and attach a copy of your discharge certificate or other certificate of active military service (if available).

See instructions for definitions of Armed Services and Uniformed Services.

a.

Branch of service

b.

Serial number

c.Dates of active duty

From (mm/dd/yyyy)

 

 

To (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.Last grade or rank

2. If any of your military service occurred on or after January 1, 1957, have you paid a deposit to your agency for this service? (You must pay this deposit to your agency.

You cannot pay OPM after you retire.)

No

Yes

Schedule B - Military Retired Pay

1.If you are receiving or have applied for military retired or retainer pay (including disability or retired pay), complete Parts 1a - 1d below.

a. Are you receiving or have you ever applied for military retired or retainer pay?

b. Was your military retired or retainer pay awarded for reserve service under

(Answer "yes" if you are receiving payments from the Department of Veterans

Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10)?

Affairs instead of military retired pay.)

 

 

 

Yes

 

No

 

 

Yes (Attach a copy of notice of award)

 

No

c.

Was

your military retired pay or retainer pay awarded for a disability incurred

d. Are you waiving your military retired or retainer pay in order to receive credit

 

in combat or caused by an instrumentality of war and incurred in the line of

 

for military service for FERS retirement benefits?

 

 

 

duty during a period of war?

 

 

 

 

Yes (Attach a copy of your request for

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes (Attach a copy of notice of

 

No

 

 

waiver and a copy of military finance

 

 

 

 

 

 

 

 

 

 

 

award)

 

 

 

 

officer's acknowledgment or approval of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your request for waiver)

 

 

Schedule C - Federal Employees Compensation Information

1.Are you receiving or have you ever received workers' compensation from the Office of Workers' Compensation Programs (OWCP), Department of Labor, because of a job-related illness or injury?

 

 

Yes (complete parts 1a - c below)

 

 

 

No (go to question 2)

 

 

 

 

 

a.

 

 

b.

Benefit received

 

c.

 

 

 

 

Compensation claim number

 

 

 

 

 

 

Type of benefit

 

 

From (mm/dd/yyyy)

 

 

To (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scheduled award

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total or partial disability compensation

 

 

 

 

 

 

 

 

 

Scheduled award

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total or partial disability compensation

2.If you have applied for workers' compensation (other than as listed in item 1a above) but are not receiving benefits, check reason below and give the information requested.

a.Awaiting OWCP decision

b. Claim denied

Compensation claim number

 

Compensation claim number

Date claim denied (mm/dd/yyyy)

3.Except for scheduled compensation awards, workers' compensation and FERS retirement benefits cannot be paid for the same period of time. Please complete the information below regarding your claim. You must complete this section.

a.Do you agree to notify us promptly if the status of your workers' compensation claim changes?

Yes

No

b.Do you authorize the Office of Personnel Management and/or the Office of Workers' Compensation Programs (OWCP) to collect any overpayment if we later find you are not eligible for both compensation and annuity payments covering the same period of time?

Applicant's Certification

I certify that all statements made on these schedules are true to the best of my knowledge and belief.

Yes

Signature (do not print)

No

Date (mm/dd/yyyy)

 

3107-108

Standard Form 3107

CSRS/FERS Handbook for Personnel and Payroll Offices

Previous editions are not usable.

Revised May 2014

Federal Employees Retirement System

 

Office of Personnel

Certified Summary of Federal Service

Management

5 CFR Part 841

Federal Employees Retirement System

 

Information for the Agency

1.A certified copy of this form must accompany the employee's Application for Immediate Retirement (SF 3107).

2.This form may also be used:

for retirement counseling purposes

to respond to an employee's request for a record of creditable service

Instructions for the Employee

1.Your employing office will complete and certify this form for you.

2.Review this form carefully. Be sure it contains all of your service.

3.Complete Section E, Employee's Certification, and return the form to your employing office.

3.See the CSRS and FERS Handbook for Personnel and Payroll Offices for detailed instructions for completion and disposition of this form.

Section A - Identification

1.

Name of employee (last, first, middle)

2.

Date of birth (mm/dd/yyyy)

3.

Social Security Number

 

 

 

 

 

 

 

 

 

 

4.

List all other names used (maiden name, AKA, spelling variants)

5.

Other birth dates used

6.

Military serial number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Service computation date for retirement

purposes

 

 

 

 

 

 

 

 

 

 

8a.

Did this employee elect to transfer to FERS?

8b.

If the employee elected to transfer to FERS, is the employee entitled, according to

 

 

 

 

 

 

your records, to have part of the FERS annuity computed under CSRS rules?

 

 

No

 

Yes, give effective date of election:

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9a.

Does

the applicant

receive military retired pay?

9b.

If yes, has the applicant waived military retired pay to credit military service for

 

 

 

 

 

 

FERS retirement?

 

 

 

 

Yes (Attach a copy of the applicant's military retired pay order,

 

 

Yes (Attach a copy of the military finance center's letter to the

 

 

 

 

 

 

if available, and complete 9b.)

 

 

employee accepting waiver, if available.)

 

 

 

 

 

 

No

 

 

 

 

No (Include cases where a waiver is not necessary.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section B - Verified Service History Documented in Official Personnel Records

Federal agency or

military service branch

Appointment, separation, or conversion dates for civilian and active honorable military service

From

To

(mm/dd/yyyy)

(mm/dd/yyyy)

 

 

Name of retirement

system*

Remarks and non-creditable time**

* Give details of creditable civilian service not subject to retirement deductions in Section C.

**In Remarks, show if CSRS service on or after January 1, 1984, is "regular" CSRS or CSRS Offset.

Indicate if service is part-time. If service was performed on a WAE or intermittent basis, show the number of days worked in "Remarks." If the number of days worked is not available, then show the number of hours worked.

CSRS/FERS Handbook for Personnel and Payroll Offices

3107-108

Standard Form 3107-1

Previous editions are not usable.

Revised May 2014

Section C - Detail of Civilian Service Not Subject to Contributory Retirement System for Civilian Federal Employees

Detail below (1) any period of Federal civilian service subject only to "FICA" deductions, and (2) any other Federal civilian service not subject to a Federal employee (or D.C. Government) retirement system. If total basic salary earned for any such period of service is known, you may make a summary entry on the right hand side below. Otherwise, show each change affecting basic salary during the period of service. Show part-time tour of duty, if applicable. Also provide total number of hours the employee worked during the period of part-time service, if available, and show what a full-time tour of duty would be. Service which is not subject to FERS or CSRS deductions is creditable only as specifically allowed by law.

Nature of action

Effective date

Basic

Salary basis

(Appt., pro.,

(mm/dd/yyyy)

salary rate

(per annum,

res., etc.)

 

 

per hour,

 

 

 

WAE, etc.)

 

 

 

 

 

 

 

 

Leave

without pay

If basic salary actually earned is available

make summary entry below

From

To

Total earned

(mm/dd/yyyy)

(mm/dd/yyyy)

 

 

 

 

Section D - Agency Certification

I certify that the information on this form accurately reflects verified information contained in official records and that the applicant has sufficient service to be entitled to an annuity. I further certify that all required documentation in support of this application is attached, accurate and complete.

Signature of authorized agency personnel official

Agency name and address, including ZIP Code, telephone number (including area code), FAX number, and EMAIL address

Official Title

Date (mm/dd/yyyy)

Section E - Employee's Certification

The service listed is complete.

I have additional service. (If you claim additional service, attach signed statement(s) giving dates, positions, titles and locations of employment, including agency, bureau, and division. Claimed service cannot be credited for retirement until it has been verified. This includes unverified service listed on an SF 144, Statement of Prior Federal Civilian and Military Service, or similar affidavit.)

Note: If you have performed Federal civilian service subject to social security deductions (FICA) or not subject to retirement deductions, be sure that your agency has correctly completed Section C above.

Signature (do not print)

Date (mm/dd/yyyy)

CSRS/FERS Handbook for Personnel and Payroll Offices

3107-108

Reverse of Standard Form 3107-1

Previous editions are not usable.

Revised May 2014

Watch Sf 3107 2 Video Instruction

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