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Question	Answer
Form Name	Sf 3107 2
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	standard form 3107 2, sf 3107 2, sfform3107 2, 3107 2

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 (?).	a.	Army, Navy, Marine Corps, Air Force or Coast
of your ability, followed by a question mark (?).		Guard of United States;
		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
	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	d.	Cadet at the U.S. Military Academy, U.S. Air
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	e.	Excluding the National Guard, active service in the
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
Item 4: Give a telephone number where you can be reached		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
Section B - Federal Service		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		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		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		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		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		1, 1990.
retirement.

Previous editions are not usable.	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			If you are married, you must have your spouse's consent
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
Box 4: If you initial Box 4, a person selected by you,			application.) The maximum combined survivor benefits
	who has an insurable interest in you, will receive		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		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		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		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		Item 1b: Indicate whether there is a court order or
	interest in you.		administrative order currently in effect that
	If you choose an insurable interest survivor		requires you to provide health benefits coverage
	If you choose an insurable interest survivor		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		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
	and who can prove good health may elect a		compensation from the Office of Workers'
	reduced annuity to provide a survivor annuity for		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		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.		because of a job-related illness or injury, check the
	retiree.		"yes" box and complete Schedule C.
			"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		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		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		2. If you have applied for, but are not receiving
	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		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
	in Relation to That of	in Annuity	time. Without this authorization from you, we
	Retiring Employee	of Retiring	time. Without this authorization from you, we
	Retiring Employee	of Retiring	will not pay your annuity until we can confirm
		Employee	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%	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
	10 but less than 15 years younger	20%	FERS annuity and compensation for total or partial
			FERS annuity and compensation for total or partial
			disability under the Federal Employees' Compen-
	15 but less than 20 years younger	25%	disability under the Federal Employees' Compen-
			sation Act.
	20 but less than 25 years younger	30%	sation Act.
	20 but less than 25 years younger	30%	Section G - Information About Children

	25 but less than 30 years younger	35%
	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
	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		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
	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		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
		3	Revised May 2014

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
		Yes	No						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
							3.	Title of position from which you are
								retiring
							3a.	Your pay plan and occupational series
							3a.	Your pay plan and occupational series

		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
						Clergyman or Justice of Peace
						Other (explain):

	3107-108	Standard Form 3107
CSRS/FERS Handbook for Personnel and Payroll Offices	Previous editions are not usable.	Revised May 2014

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	to _______________%
		(mm/dd/yyyy)		of my annuity
				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	to _______________%
		(mm/dd/yyyy)		of my annuity
				of my annuity


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

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


		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
	or voluntary contributions)?

2a.	Type of application		Refund		Deposit or redeposit	2b.	Claim number(s)
		Retirement	Return of excess deductions		Voluntary contributions

3.Disabled 1.	Dependent child's name
()	(first, middle, last)

Signature (Do not print)	Date (mm/dd/yyyy)

	Office of Personnel
Certified Summary of Federal Service	Management
Certified Summary of Federal Service	5 CFR Part 841
Federal Employees Retirement System

	3107-107
CSRS/FERS Handbook for Personnel and Payroll Offices	Previous editions are not usable.

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

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
	duty during a period of war?

		Yes (Attach a copy of notice of	No			waiver and a copy of military finance
		Yes (Attach a copy of notice of	No			waiver and a copy of military finance
		award)				officer's acknowledgment or approval of
		award)				officer's acknowledgment or approval of
						your request for waiver)

	Yes (complete parts 1a - c below)			No (go to question 2)
a.		b.	Benefit received		c.
	Compensation claim number					Type of benefit
	Compensation claim number	From (mm/dd/yyyy)		To (mm/dd/yyyy)		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

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
		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.)
		if available, and complete 9b.)					employee accepting waiver, if available.)
		No					No (Include cases where a waiver is not necessary.)
		No					No (Include cases where a waiver is not necessary.)

CSRS/FERS Handbook for Personnel and Payroll Offices	3107-108	Standard Form 3107-1
CSRS/FERS Handbook for Personnel and Payroll Offices	Previous editions are not usable.	Revised May 2014

Nature of action	Effective date	Basic	Salary basis
(Appt., pro.,	(mm/dd/yyyy)	salary rate	(per annum,
res., etc.)			per hour,
			WAE, etc.)

CSRS/FERS Handbook for Personnel and Payroll Offices	3107-108	Reverse of Standard Form 3107-1
CSRS/FERS Handbook for Personnel and Payroll Offices	Previous editions are not usable.	Revised May 2014

Name of person with insurable interest

Relationship to you

Date of birth (mm/dd/yyyy)

Social Security Number

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