SF-3107-2 Form – Fill Out and Use This PDF

Spouse's Consent to Survivor Election

Instructions: If you are married and you do not elect a red uced annuity to provide a maximum survivor annuity for your current spouse, complete Part 1. Have your spouse complete Part 2. Part 2 must be completed in the presence of a Notary Public or other person authorized to administer oaths. The person administering oaths must complete Part 3.

Part 1 - To Be Completed by the Retiring Employee

1 have elected: (Mark the box(es) which describes the survivor election(s) you have made. More than one box may be marked.)

Part 2 - To Be Completed by the Current Spouse of the Retiring Employee

1 freely consent to the survivor annuity elect ion described in Part 1. / understand that if nu• spouse elected 110 regular or insurable interest survivor a111111i~)• in Part I.a. above, I will not recei ve a survivor annuity, my health benefits coverage will terminate and I will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) if I am not already enrolled bef ore my spouse's death. I also understand tlwt my consent is final (not revocable).

Part 3 · To Be Completed by a Notary Public or Other Person Authorized to Administer Oaths

I certify that the person named in Part 2 presented identification (or was known) to me, gave consent, signed or marked this form and acknowledged that the consent was freely given in my presence on this

the _____ day of ________ ____, ---- , -- ~ at _ ___ _______,, --- . , ------------ -

Privacy Act Statement

Solici1a1io11 of this infonnation 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). 11,e infonnation you fumish will be used 10 identify records properly associated with your application for Federal

benefits. 10 obtain additional infonnalion ifnecessary, to dctcm1ine and allow present or future benefi1s, :rnd to maintain a unique identifiable claim fi le. The infonnation may be shared and is subject 10 vcrifica1ion via paper, electronic media, or throu~h the use of computer matching programs with national. slate, loc,11 or other charitable or social security administrative agencies in order to dctcnninc benefits under their programs. to obtain infonnnuon necessary for dctcnnination or continuation of benefits under this progr:un. or to repon income for tax purposes. It may also be shared :md \'Crificd, as noted abo\'e. with law enforcement agencies when they arc in\'cstigating a violation or potenlial violn1ion of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number. 111c Govenunent may use your number in collecting and reponing amounts that you owe the Government. Furnishing the Social Security Number. as well as other data, is voluntary, but fai lure to do so may delay or prevent ac1ion on the rct ircmenl applicalion.