Standard Form 2801 – Fill Out and Use This PDF

Introduction

If you are a current Federal or Postal Service employee covered by the Civil Service Retirement System and you wish to apply for retirement with an immediate annuity (annuity commencing within one month after the date of separation on which title to annuity is based), this package is for you! If you are covered by the Federal Employees Retirement System, you must use SF 3107 to apply for an immediate annuity retirement.

If you are applying for disability retirement, you must complete both this application and Standard Form 3112, Application for Disability Retirement. Ask your agency for this form. You, your physician, and your agency must complete the various portions of SF 3112. The Office of Personnel Management (OPM) must receive the SF 3112 within one year after the date you separate.

Do not use this package or the forms it contains to apply for deferred annuity. If you want to apply for a deferred annuity (generally beginning at age 62), you should request an application from the Office of Personnel Management, Civil Service Retirement System, Retirement Operations Center, Boyers, PA 16017.

Keep the information section of this package for future reference.

Where to Obtain Additional Information This package presents basic retirement information about matters affecting most retiring employees. Contact the Human Resources Office at the agency where you work for retirement counseling, detailed information, and other assistance you need to prepare for retirement. Your agency must certify that you are eligible for an immediate annuity. OPM employees cannot advise you before you are separated and your certified records are forwarded to OPM.

General Information

This package contains the following:

1)Instructions for the completion and submission of the SF 2801, Schedules A, B, C, and SF 2801­2.

2)Additional information about retirement, including:

•Post­1956 Military Service, page 4

•Important Information About Survivor Annuity Elections, page 5

•Survivor Annuity Election Changes After Retirement, page 7

•How Annuities Are Computed, page 8

•Cost­of­Living Increases, page 10

•Payment and Accrual of Annuity, page 10

•Filing Your Application, page 10

•What Happens After You File Your Retirement Application, page 11

•What To Do If Your Address Changes Before Processing Is Completed, page 11

3)SF 2801, Application for Immediate Retirement, to be completed and signed by the retiring employee.

4)Schedules A, B, and C to be completed by the retiring employee if he or she has (1) active duty military service,

(2) has ever applied for military retired pay and/or pension or compensation from the Department of Veterans Affairs in lieu of military retired pay, or (3) has applied for compensation benefits from the Office of Workers' Compensation Programs, U.S. Department of Labor.

5)SF 2801­2, Spouse's Consent to Survivor Election, to be completed by the retiring employee, his or her current spouse, and a notary public (or other person authorized to administer oaths) in cases where a married applicant elects less than the maximum survivor annuity for the spouse.

6)SF 2801­1, Certified Summary of Federal Service, to be completed by the employing agency and signed by the applicant after reviewing the information the employing agency enters.

7)Agency Checklist of Immediate Retirement Procedures, to be completed by the employing agency and, to the extent possible, reviewed by the retiring employee to help assure completeness and correctness of the submission.

Instructions for Completing Application for Immediate Retirement

Type or print clearly. If you need more space in any section, use a plain piece of paper with your name and date of birth written at the top. If you do not know an answer write “unknown.” If you are not sure (for example, if you do not know an exact date), answer to the best of your ability, followed by a question mark (?).

Refer to the pamphlet SF 2801A, Applying for Immediate Retirement Under the Civil Service Retirement System, for additional information about those questions on the application which are not entirely self­explanatory.

Section A - Identifying Information

Item 2: List other names under which you have been employed in the Federal government (such as a maiden name). This will help OPM locate and identify records maintained under these names.

Item 3: Enter the address to which correspondence should be mailed. If you want your payments sent to a bank or other financial institution, do not enter the bank address here; see Section H of the application form.

Item 6: List all social security numbers you have used.

Section B - Federal Service

Item 2: Enter the date of final separation for retirement. Leave blank if applying for disability retirement and not yet separated. Please note that if you are currently serving in more than one appointive or elective position in the Federal Government, you must separate from all such positions before you can qualify for an immediate retirement.

Item 4: Indicate whether or not you have performed active duty that terminated under honorable conditions in the armed forces or other uniformed services of the United States, including the following:

(a)Army, Navy, Marine Corps, Air Force, or Coast Guard of the United States,

(b)Regular Corps or Reserve Corps of the Public Health Service after June 30, 1960,

(c)Commissioned Officer of the National Oceanic and Atmospheric Administration or a predecessor entity in function after June 30, 1961.

(d)Cadet at the U.S. Military Academy, U.S. Air Force Academy, U.S. Coast Guard Academy, or Midshipman at the U.S. Naval Academy.

(e)Excluding the National Guard, active service in the reserve components of the uniformed services, including active duty for training, is military service. Service as a National Guard member does not meet the definition of military service for purposes of civil service retirement, except when the member is ordered to active duty in the service of the United States or performs full­time National Guard Duty (as such term is defined in section 101(d) of title 10) if the National Guard duty interrupts creditable civilian service under subchapter III of chapter 83 of title 5, and is followed by reemployment in accordance with chapter 43 of title 38 that occurs on or after August 1, 1990.

If you have performed such service, complete and attach Schedule A, furnishing the requested information from the military for each period of active duty. Provide evidence of active duty you claim. You are responsible for obtaining this information and submitting it to OPM to substantiate your claim. OPM may verify the information with the military service.

Item 5: If you are receiving, or have applied for, any form of military retired pay and/or pension or compensation 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. Important: Military retired pay includes disability pay and reserve retainer pay.

Section C - Other Claim Information

Item 2: Indicate whether or not you have ever applied for retirement, refund, deposit or redeposit, return of excess deductions, or voluntary contributions under the Civil Service Retirement System. If you have, indicate which type in 2a and the applicable claim numbers in 2b. This helps to assure that all of your records are located and that proper credit is given for your service, and for any deposit, redeposit or voluntary contribution payments you may have made.

Section D- Insurance Information

If you want to continue your Federal Employees Health Benefits (FEHB) and/or Federal Employees' Group Life Insurance (FEGLI) coverage as a retiree, you must meet the following basic requirements. You must be retiring on an

immediate annuity, and you must have been enrolled in the program for the five years of Federal service immediately preceding your annuity commencing date, or if enrolled less than five years, for the full period(s) of service during which coverage was available. FEHB coverage as a family member (and coverage under TRICARE) counts toward the five­year requirement for health benefits.

If you do not meet the enrollment requirement for continuing your FEHB coverage as a retiree, you may be eligible for temporary continuation of coverage as a separated employee. Your employing office will provide information about whether you can temporarily continue your FEHB coverage and how to enroll for it.

If you appear eligible to continue your FEHB coverage, your agency will automatically transfer your enrollment to OPM. You do not need to do anything unless you want to make some change in your coverage.

If you are enrolled in the Federal Dental and Vision Program (FEDVIP), you may be billed for the premiums from the time you separate for retirement until OPM completes work on your retirement application. You must pay these bills in order to keep your FEDVIP coverage. After work on your retirement application is completed, OPM will deduct your FEDVIP premiums from your monthly annuity payments. If you retire on an immediate annuity, you can enroll in FEDVIP during any Federal Benefits Open Season.

The FEGLI Program booklet (RI 76­21) has information about eligibility to continue your FEGLI coverage as a retiree and the cost of coverage. If you are eligible to continue your FEGLI basic coverage, you MUST complete an SF 2818, Continuation of Life Insurance Coverage as an Annuitant or Compensationer. Any optional FEGLI coverage you have and are eligible to retain as a retiree will automatically be continued unless you make some change. You may also want to file a FEGLI Designation of Beneficiary form (SF 2823).

If you are under age 65 and elect to continue Basic life insurance coverage into retirement, you must pay the same premium as active employees until you reach age 65. If you elect either the 50% or No Reduction schedule (for coverage after reaching age 65) on the SF 2818, you must pay not only the regular insurance premium but also the additional premium required for the extra coverage you will have after age 65. Premiums for the additional coverage after age 65 continue for life or for as long as you maintain the extra coverage.

Based on the documentation your employing agency is required to submit with your retirement application, OPM will determine whether you are eligible to continue your health and life insurance coverage as a retiree. However, if you have any questions about your eligibility, ask your employing office for assistance before you retire.

Section E - Marital Information

Item 2: You must complete this item. Indicate whether or not you have a living former spouse from whom you were divorced on or after May 7, 1985, and to whom a court order gives a survivor annuity or awards a portion of your retirement benefit based on your Federal employment.

If you answer yes, attach a certified copy of the court order/divorce decree in its entirety and any attachments or amendments. Failure to complete this item will delay the processing of your application.

Section F - Annuity Election

Read “Important Information About Survivor Annuity Elections,” page 5, before making your election. If you initial either Box 1 or Box 2, your wife or husband will receive a survivor annuity upon your death. The amount of this survivor annuity, and the amount of the reduction in your annuity to provide this benefit, will depend on which election you initial.

If your spouse is not elected to receive a monthly survivor annuity, his or her health benefits coverage as a family member on your FEHB enrollment will terminate when you die.

For information on the effect of court orders on your spouse's eligibility to receive survivor benefits, see page 5.

Box 1: If you initial box 1, your spouse's survivor annuity upon your death will be 55% of your unreduced annuity. Your annuity will be reduced by 2½ percent of the first $3,600 and 10% of the remainder of your annual annuity to provide this benefit upon your death.

Box 2: If you initial box 2, your spouse's survivor annuity upon your death will be 55% of the annual amount you specify in the blank space (which must be less than the full amount of your annual annuity). Your annuity will be reduced by 2½ percent of the first $3,600 and 10% of any additional amount you specify.

If you initial box 2, you must complete and attach SF 2801­2, Spouse's Consent to Survivor Election, to your application. The law requires consent of the spouse if a married person elects less than the maximum survivor benefit.

Box 3: If you initial box 3 you will receive an annuity payable only during your lifetime, without a monthly survivor annuity for your spouse. All retiring employees, married and unmarried, may choose this type of annuity. However, you should carefully review all information provided before making your election.

If you are married at retirement and choose this type of annuity, you must also complete and attach to your application SF 2801­2, Spouse's Consent to Survivor Election. The law requires that your spouse consent if you elect less than maximum survivor benefits.

Box 4: If you initial box 4, a person selected by you, who has an insurable interest in you, will receive a survivor annuity upon your death. Insurable interest exists if the person named (such as a former spouse or a close relative) may reasonably expect to derive financial benefit from your continued life.

To choose this type of annuity, you must provide medical documentation showing that you are in good health. You are responsible for arranging and paying the costs of the medical examination. The medical report of the examination should be attached to your retirement application. You will be notified if additional evidence is required. Note: If you are retiring on the basis of disability, you are not eligible to choose this type of annuity.

You may elect this insurable interest survivor annuity in addition to a regular survivor annuity for a current or former spouse. However, if the person you select to receive the insurable interest survivor annuity is your current spouse, you both must waive the

current spouse annuity by completing and attaching SF 2801­2 to your application. Your current spouse cannot receive both a regular survivor annuity and an insurable interest survivor annuity.

If you elect the insurable interest annuity for a current spouse because a court order awards (or you have elected) the regular survivor annuity to a former spouse, the insurable interest election for your current spouse can be converted to a current spouse annuity if the former spouse loses entitlement to the regular annuity through death or remarriage prior to reaching age 55. The marriage duration requirement (see item c on page 5) does not apply to insurable interest annuities.

If you choose to provide an insurable interest survivor annuity, the amount of the reduction in your annuity will depend upon the difference between your age and the age of the person named as survivor annuitant, as shown in the table below. The survivor's rate will be 55% of your reduced annuity.

Box 5: If you initial box 5, you must complete the remainder of Section F. Read item f. on page 5 before making your election. If you are married and initial box 5, you must also complete and attach SF 2801­2, Spouse's Consent to Survivor Election, to your application.

If you initial box 5, after your death, the person(s) you elect will receive the percentage of the annuity you select. Your annuity will be reduced by 2½ percent of the first $3,600 of all or a specified amount of your annual self­only annuity and further reduced by 10% for any portion of the base used over $3,600 a year. If your annual annuity is $3,600 or less, only a 2½ percent reduction applies.

Section G - Information About Children Information about your children in your annuity claim file may help to expedite the processing of claims for survivor benefits in the event of your death. Therefore, you may, if you wish, complete Section G by providing the names and the dates of birth of your unmarried dependent children under the age of 22. List any child who is between 18 and 22 and is a full­time student. List any child who is over the age of 18 and incapable of self­support because of a mental or physical disability incurred before age 18. Check the box headed “disabled” by the name of each child to whom this applies.

Completion of Section G is optional; the processing of your annuity application will not be delayed or otherwise affected if you do not complete it. Children will not be denied benefits after your death solely because they were not identified on your retirement application.

Section H - Direct Deposit/Direct Express and Tax Withholding Information

The U.S. Department of the Treasury pays all federal benefits electronically. If you are not enrolled in the Direct Deposit program, you will need to enroll or to arrange for a Direct Express debit card provided by the Department of Treasury. To enroll in the Direct Deposit program, contact your financial institution or OPM. To obtain a debit card, go to www.godirect.org. 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 1­800­333­1795 to discuss your options. This does not apply if your permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. Use Section H, items 1 through 3c to tell OPM how to make payment to you.

Use Section H, item 4 to give OPM instructions regarding Federal income tax withholding. If you do not give any instructions, the Internal Revenue Service has instructed OPM to withhold at the rate for a married person with three exemptions.

After your application is processed, as discussed on page 11, item 6, you will be able to instruct OPM to withhold State income tax, provided your State participates in OPM's State Tax Withholding Program.

Section I - Applicant's Certification

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

Schedule A - Military Service Information

Item 2: Post-1956 Military Service ­­ If you performed military service on or after January 1, 1957, you may pay a deposit of 7% of your military basic pay (plus interest, if applicable) to cover that service. The military service deposit must be paid to your agency while you are still employed. If the deposit is not paid, your post­1956 military service will be credited as described below.

If you were first employed in a position subject to CSRS coverage before October 1, 1982: If you do not make the deposit and you are eligible for Social Security benefits at age 62, your annuity will be recomputed (at age 62) to eliminate credit for the post­1956 military service. If you are age 62 or older when you retire and are eligible for Social Security benefits, no credit for post­1956 military service will be allowed in the computation of your annuity unless you pay the deposit before you separate.

If you were first employed in a position subject to CSRS coverage on or after October 1, 1982: You will not receive any retirement credit for your post­1956 military service if you do not make the deposit for it before you separate.

The amount of a CSRS military deposit may be different for an employee who has been absent from civilian employment to perform honorable, active military service that interrupted Federal civilian service. Under certain conditions, the amount of the military deposit for such a period of military service would equal the amount of retirement deductions that would have been withheld from Federal civilian basic pay if the military service had not interrupted the civilian service. Ask your benefits office about this alternative military deposit calculation referenced in 5 U.S.C. 8334(j) if you think it may apply to you.

If you have questions concerning the crediting of your post­1956 military service and how to make the deposit, contact your employing agency. Failure to pay the deposit to your agency voids any further right to pay it at a later date.

Schedule B - Military Retired Pay

This information is needed to assure correct credit for military service. Receipt of military retired pay or pension or compensation from the Department of Veterans Affairs in lieu of military retired pay may affect the computation of your annuity rate. You cannot receive retirement credit for military service if you receive military retired pay, unless you were awarded the retired pay (a) due to a disability incurred in combat with an enemy of the United States or

(b)under the provisions of Chapter 1223, title 10, U. S. Code, Sections 12731 through 12739 (pertaining to retirement from a reserve component of the armed forces).

If you are waiving military retired pay for civil service retirement purposes, your agency can help you prepare your request for waiver. Attaching a copy of your waiver request and a copy of the finance center 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 of your military pay for civil service retirement purposes.

Schedule C - Federal Employee's Compensation Item 3: Indicate whether you agree to notify us if the status of your workers' compensation claim changes.

Important: You may not legally receive both retirement annuity and workers' compensation (except for a scheduled award) for the same period of time. Any overpayment of workers' compensation or retirement annuity you receive is subject to collection by OPM or the Office of Workers' Compensation Programs (OWCP).

The information requested regarding benefits from OWCP is needed because the law prohibits the dual compensation which would exist if you received both a civil service retirement annuity and compensation for total or partial disability under the Federal Employees' Compensation Act. Note: The Department of Labor has determined that the alternative annuity lump sum payment is a payment within the terms of the dual compensation provision. If you receive the alternative annuity lump sum payment and later elect compensation from OWCP, no compensation would be payable until the amount of the lump sum payment and all annuity paid is returned to the Retirement Fund.

If you are applying for disability retirement, please include, as part of your SF 3112 submission, all medical evidence submitted to OWCP in connection with your compensation claim and any OWCP decision or evaluation of your claim.

Important Information About

Survivor Annuity Elections

The election you make at retirement is for the person named in Section E. No one else can benefit even if you allow the annuity reduction to continue after your marriage ends.

a.Married Employees. If you are married at retirement and do not indicate your annuity election or your spouse does not consent to an election of less than the maximum survivor annuity, your application will be processed on the basis of maximum survivor benefits for your spouse.

b.Spousal Consent Requirement.

(1)If you are married and you do not elect to provide the maximum survivor annuity benefit for your spouse by initialing Section F, box 1 of the application, you must attach a completed SF 2801­2, Spouse's Consent to Survivor Election. This is required even if a former spouse will be awarded a survivor annuity by court order. See “Court­Ordered Former Spouse Annuities” under item e.

(2)OPM may waive the spousal consent requirement if you show that your spouse's whereabouts cannot be determined. A request for waiver on this basis must be accompanied by:

•A judicial determination that your spouse's whereabouts cannot be determined; or

•Affidavits by you and two other persons, at least one of whom is not related to you, attesting to the inability to locate the current spouse and stating the efforts made to locate the spouse. You must also give documentary evidence, such as tax returns filed separately or newspaper stories about the spouse's disappearance.

(3)OPM may waive the spousal consent requirement if you present a judicial determination regarding the current spouse that would warrant waiver of the consent requirement based on exceptional circumstances.

c.Marriage Duration Requirement. To be eligible for survivor annuity after your death, your widow(er) must have been married to you for a total of at least 9 months or be a parent of your child, provided all other requirements are met. The marriage duration requirement does not apply if your death is accidental.

d.Survivor Annuity for Children. The eligibility of your children for survivor annuity after your death does not depend on your marital status or the type of annuity you elect. Your unmarried dependent children may qualify for survivor annuity until age 18. Benefits may be payable to an unmarried child after age 18 if the child is a full­time student at a recognized educational institution or is incapable of self­support due to a disability incurred before age 18. Benefits for a student child are generally not payable after the child attains age 22.

e.Court-Ordered Former Spouse Annuities. If your annuity begins on or after May 7, 1985, and a qualifying court order gives (awards or requires you to provide) a survivor annuity to a former spouse from whom you were divorced on or after that date, OPM must honor the terms of the court order, except as discussed below. Your annuity will be reduced to provide the survivor annuity for the former spouse if he or she is eligible for this benefit. However, a former spouse cannot receive a survivor annuity by court order unless:

(1)He or she was married to you for at least 9 months;

(2)You have at least 18 months of service subject to retirement deductions; and

(3)He or she has not remarried before reaching age 55. This does not apply if you and your former spouse were married for 30 years or longer.

If you are married and a court has awarded a survivor annuity to a former spouse, see item g. below, which explains how you can protect your current spouse's future survivor annuity rights.

f.Electing a Survivor Annuity For a Former Spouse or a Combination of Survivor Annuities For Current and Former Spouses.

(1)To make a former spouse annuity election, you must have been married to the person for a total of at least 9 months and you must have at least 18 months of service that was subject to retirement deductions. A former spouse who marries again before reaching age 55 is not eligible for a former spouse survivor annuity, unless you and your former spouse were married for 30 years or longer.

(2)You may elect to provide a survivor annuity for more than one former spouse whether or not you are currently married. If you are married, you may elect a survivor annuity for your current spouse as well as a survivor annuity for one or more former spouses. However, the total of the survivor annuities may not exceed 55% of your unreduced annuity. Also, if you are married, you must have your spouse's consent if you do not elect the maximum current spouse survivor annuity.

(3)To elect a reduced annuity to provide a survivor annuity to a former spouse or a combination of survivor annuities

for current and former spouse(s), complete Section F, box 5.

g.Electing a Survivor Annuity For a Current Spouse When a Court Order Gives a Survivor Annuity to a Former Spouse.

(1)If a court order has given a survivor annuity to a former spouse, you must make your election concerning a survivor annuity for your current spouse as if there were no

court­ordered former spouse annuity. By electing the maximum survivor benefit for your current spouse at retirement, you can protect your spouse's rights in case your former spouse loses entitlement in the future (because of remarriage before age 55 or death). You can do this because OPM must honor the terms of the court order and you are not required to elect a survivor annuity for the former spouse. (Note: The election you make now regarding a survivor annuity for your current spouse cannot be changed except as explained in “Survivor Annuity Election Changes After Retirement,” see page 7.) The following paragraphs explain in more detail how your election at the time of retirement can affect your current spouse's future rights if the court has given a survivor annuity to a former spouse.

(2)If a court order gives a survivor annuity to a former spouse, your annuity will be reduced to provide it. If you elect a full or partial survivor annuity for your current spouse (or another former spouse), your annuity will be reduced no more than it would be reduced to provide a survivor annuity equal to 55% of your unreduced annuity.

(3)If you die before your current and former spouses, the total amount of the survivor annuities paid cannot exceed 55% of your annuity. OPM must honor the terms of the court order before it can honor your election. The former spouse having the court­ordered survivor benefit would receive an annuity according to the terms of the court order.

(4)If the court order gives the maximum survivor annuity to the former spouse, your widow(er) would receive no survivor annuity until the former spouse loses entitlement. Then your widow(er) would receive a survivor annuity according to your election.

(5)If the court order gives less than the maximum survivor annuity to the former spouse, your widow(er) would receive an annuity no greater than the difference between the court­ordered survivor annuity and 55% of your annuity. However, if the former spouse loses entitlement to the survivor annuity (through remarriage before age 55 or death), your widow(er)'s survivor annuity would be increased to the amount you elected.

For example, if there is a court­ordered former spouse survivor annuity that equals 40% of your annuity, you elect the maximum survivor annuity for your current spouse, and you die before the former spouse's entitlement to a survivor annuity ends, the former spouse would receive a survivor annuity equal to 40% of your annuity and your widow(er) would receive a survivor annuity equal to 15% of your annuity. However, if the former spouse later loses entitlement to the survivor annuity (through remarriage before age 55 or death), your widow(er) would then receive a survivor annuity equal to 55% of your annuity.

(6)FEHB coverage for your widow(er) can continue only if he or she is elected to receive a survivor annuity.

h.Electing an Insurable Interest Annuity For a Current Spouse.

Note: Disability annuitants cannot elect an insurable interest survivor annuity.

(1)If a former spouse's court­ordered survivor annuity will prevent your current spouse from receiving a survivor annuity that is sufficient to meet his or her anticipated needs, you may want to elect an insurable interest annuity for your current spouse.

(2)If you elect an insurable interest survivor annuity for your current spouse, you and your current spouse must both waive the regular survivor annuity. To do this:

(a)initial and complete box 4 in Section F of the SF 2801 naming your current spouse;

(b)complete Part 1 of SF 2801­2 and check box b;

(c)have Parts 2 and 3 of SF 2801­2 properly completed (i.e., spouse's consent to insurable interest benefit in lieu of regular survivor annuity).

(3)If you elect an insurable interest survivor annuity for your current spouse and your former spouse loses entitlement before you die, you may request that the reduction in your annuity to provide the insurable interest annuity be converted to the regular spouse survivor annuity. (See “Survivor Annuity Election Changes After Retirement,” see page 7.) Your current spouse would then be entitled to the regular survivor annuity. If your former spouse loses entitlement after you die, your widow(er) can substitute the regular survivor annuity for the insurable interest survivor annuity.

(4)If for any reason OPM cannot allow your insurable interest election for your current spouse, your current spouse will be considered elected for a maximum regular survivor annuity, unless your current spouse signs another SF 2801­2 consenting to less than a maximum regular survivor annuity.

i.Voluntary Contributions and Survivor Annuity Election.

The following information applies only to employees who have made voluntary contributions to purchase additional annuity (see page 10), or who are using excess retirement deductions (see “80% Limitation on Basic Annuity” on page 8) as voluntary contributions.

(1)Survivor annuity that is purchased by voluntary contributions is not subject to the spousal consent requirement discussed on page 5, nor is it subject to court orders awarding survivor benefits to former spouses. Therefore, regardless of your marital status at retirement or the type of survivor election you make for your regular annuity:

(a)You may elect not to provide a survivor annuity based on the voluntary contributions, or

(b)You may name any individual you want to receive the voluntary contributions survivor annuity. That is, the individual you name to receive the voluntary contributions survivor annuity does not need to be the same person you name as survivor annuitant under the regular survivor election made in Section F of SF 2801.

(2)If you are married and elect to provide a regular survivor annuity for your spouse (by checking box 1, box 2, or box 4 of Section F on the SF 2801), your voluntary contributions annuity will automatically be reduced to provide an additional survivor annuity for your spouse, unless you attach a signed statement to your application for retirement in which (a) you state that you do not want to provide a survivor annuity based on the voluntary contributions or (b) you name another person to receive this benefit as explained in (4) below.

(3)If you are single and elect an annuity payable only during your lifetime or if you are married and with your spouse's consent elect an annuity payable only during your lifetime (by checking box 3 of Section F on the SF 2801), your additional annuity purchased by voluntary contributions will not be reduced to provide a survivor annuity, unless you elect otherwise as explained below.

(4)If you want to designate an individual to receive a survivor annuity based on your voluntary contributions, you must submit a signed statement which names the person who is to receive the voluntary contributions survivor annuity. (Only one person may be named.) The signed statement must be attached to your application for retirement. If you are electing a survivor annuity for a person other than a current spouse, the statement must include that person's full name, date of birth, social security number, and mailing address. (In this instance, you must also provide proof of the person's date of birth, such as a certified birth certificate.)

(5)The reduction in your voluntary contributions annuity to provide a survivor annuity based on your voluntary contributions depends upon the difference between your age and the age of the person named to receive the survivor annuity as shown in the table on page 3.

The survivor's rate is 50% of your additional annuity after it is reduced to provide a survivor benefit. Important: The reduction to provide the voluntary contributions survivor annuity will not be eliminated if the person you elect to receive this benefit dies, nor can you substitute another individual to receive the benefit.

Survivor Annuity Election Changes

After Retirement

a.You may name a new survivor or change your election if, not later than 30 days after the date of your first regular monthly payment, you file a new election in writing. If the person you named to receive a survivor annuity dies or your current marriage ends in death, divorce or annulment, you should write OPM, Retirement Operations Center, Boyers, PA 16017. (Note: If your marriage to the spouse you had at retirement continues, you must have his or her consent to any election that does not provide the maximum current spouse survivor annuity.)

Your first regular monthly payment is the first recurring annuity payment (other than an estimated payment or an adjustment) after OPM has determined your regular rate of annuity payable under CSRS and has paid the annuity accrued since the time you retired.

b.When the 30­day period following the date of your first regular monthly payment has passed, you cannot change your election except under the circumstances explained in the following paragraphs.

c.You may change your decision not to provide a survivor annuity for your spouse at retirement or you may increase the survivor annuity amount for your spouse at retirement if you request the change in writing no later than eighteen months after the commencing date of your annuity. You must also pay a deposit with interest representing the difference between the reduction for the new survivor election and the original survivor election, plus a charge of $245.00 for each thousand­dollar change in the designated survivor's base. Such an election would cancel any joint waivers made at retirement. However, the total survivor annuity(ies) provided for former spouses (by court order or election) and the current spouse cannot exceed 55% of your annuity. Note, you can make a contingent election of 55% for your current spouse even if there is a court order.

d.The reduction in your annuity to provide a survivor annuity for your current spouse stops if your marriage ends because of death, divorce, or annulment. However, you may elect, within 2 years after the marriage ends, to continue the reduction to provide a former spouse survivor annuity for that person, subject to the restrictions in paragraph j.

If you marry someone else before you make this election, your new spouse must consent to your election.

e.The reduction in your annuity to provide a survivor annuity for a former spouse ends (1) when the former spouse dies, (2) when the former spouse remarries before reaching age 55, or (3) under the terms of the court order that required you to provide the survivor annuity for the former spouse when you retired. (Modifications of the court order issued after you retire do not affect the former spouse annuity.) If you and your former spouse were married for 30 years or longer, the reduction does not end. However, if at retirement, you had elected a survivor annuity for your current spouse (or another former spouse), the reduction will be continued to provide

annuity for that person. If you have not previously made an election regarding a current spouse whom you married after retirement (or if your election regarding a current spouse at retirement was based on a waiver of spousal consent), you may, within 2 years after the former spouse is no longer eligible because of remarriage before age 55 or death, elect a reduced annuity to provide a survivor annuity for that current spouse. This election is subject to the restrictions given in paragraph j.

f.If you were not married at retirement, you may elect, within 2 years after a post­retirement marriage, a reduced annuity to provide a maximum or less­than­maximum survivor annuity for your spouse, subject to the restrictions given in paragraph j.

g.If you were married at retirement, that marriage ends, and you marry again, you may elect a reduced annuity to provide a maximum or less­than­maximum survivor annuity for your new spouse, subject to the restrictions given in paragraph j. Please note that the survivor annuity elections automatically terminate upon divorce. You must make a new election within

2 years after the divorce to provide a survivor annuity for a former spouse. Continuing a survivor reduction, by itself, is not a former spouse survivor election. If you remarry the same person you were married to

at retirement and that person had previously consented to your election of no survivor annuity, you may not elect to provide a survivor annuity for that person when you remarry.

h.If, at retirement, you received (by election or court order) a reduced annuity to provide a survivor annuity for a former spouse and you elected to provide an insurable interest survivor annuity for your current spouse, you may change the insurable interest election to a regular current spouse survivor annuity within 2 years after your former spouse loses entitlement (because of remarriage before age 55, death, or the terms in the court order), subject to restrictions (1) and (2) given in paragraph j.

i.The reduction in your annuity to provide an insurable interest survivor annuity ends if the person you named to receive the insurable interest annuity dies or when the person you named is your current spouse and you change your election as explained in paragraph h. The reduction also ends if, after you retire, you marry the insurable interest beneficiary and elect to provide a regular survivor annuity for that person. If you marry someone other than the insurable interest beneficiary after you retire and elect to provide a regular survivor annuity for your new spouse, you may elect to cancel the insurable interest reduction.

j.Post­retirement survivor elections are subject to the following restrictions:

(1)They cannot be honored to the extent that they conflict with the terms of a qualifying court order that requires you to provide a survivor annuity for a former spouse.

(2)They cannot be honored if they cause combined current and former spouse survivor annuities to exceed 55% of your unreduced annuity; and

(3)If, during any period after you retired, your annuity was not reduced to provide a current or former spouse survivor annuity, you must pay into the retirement fund an amount equal to the amount your annuity would have been reduced during that period plus 6% annual interest.

k.Insurable interest elections are not available after retirement.

How Annuities Are Computed

The following discussion is not detailed enough to answer every question you may have. Your agency is responsible for giving you an annuity estimate and specific advice about your individual circumstances.

Basic Annuity Computation — The amount of your annuity depends primarily on your “high­3” average pay and length of service.

Unused Sick Leave — An employee who retires with unused sick leave will have the number of working days represented by such leave added to the years of service for the purpose of computing the annuity. Additional annuity earned thereby will not be subject to the 80% limitation on basic annuity. Days of unused sick leave may not be used in determining average pay or length of service for annuity eligibility.

High-3 Average Pay — The “high­3” average pay is the highest pay obtainable by averaging the rates of basic pay in effect during any 3 consecutive years of service with each rate weighted by the time it was in effect.

Basic Annuity Formula — For employees generally, (a) take: 1½ percent of the “high­3” average pay and multiply the result by 5 years of service; (b) add: 1¾ percent of the “high­3” average pay multiplied by years of service between 5 and 10; and (c) add: 2% of the “high­3” average pay multiplied by all service over 10 years.

Formula for Law Enforcement and Firefighter Personnel

—The basic annuity of an employee who retires under the special provision covering law enforcement, firefighter and nuclear materials courier personnel is 2½ percent of the “high­3” average pay multiplied by 20 years of law enforcement, firefighter and/or nuclear materials courier service, plus 2% of the “high­3” average pay multiplied by all service over 20 years.

Other Special Computations — Information concerning other special computations, such as those for certain air traffic controllers, customs and border protection officers, nuclear materials couriers, Members of Congress, Congressional employees, retirement under provisions of the Panama Canal Treaty, etc., must be obtained from your employing agency.

80% Limitation on Basic Annuity — The basic annuity may not be more than 80% of the employee's “high­3” average pay. Retirement deductions withheld after the month the 80% limitation is reached are, at separation, set aside as a special credit. At retirement, this special credit is applied to any unpaid deposit or redeposit. Any balance, or the entire special credit if no deposit is due, is refundable before annuity has been granted or may be used as voluntary contributions to purchase additional annuity as explained below.

Guaranteed Minimum Disability Annuity — An employee retiring before age 60 on account of total disability is guaranteed a minimum basic annuity which amounts to the lesser of (a) 40% of the “high­3” average pay or (b) the sum obtained by using the basic annuity formula above, but increasing the length of actual service by the period between the date of the employee's separation for retirement and the date age 60 is reached.

If the basic annuity is greater than the guaranteed minimum, the basic annuity is paid instead. Persons receiving military retired pay or pension or compensation from the Department of Veterans Affairs in lieu of military retired pay are generally not eligible for the guaranteed minimum annuity computation.

Reductions to the Basic Annuity — There are several possible reductions to the basic annuity. These include:

a.Service You Have Not Paid For — Civilian service during which no retirement deductions were withheld from your salary is called “nondeduction” service.

A “deposit” is a payment to the retirement fund to cover a period of nondeduction service. You do not have to make a deposit if you do not wish to do so. This can affect the amount of your monthly annuity.

However, this service is creditable for title to annuity and may be used as needed in computing your “high­3” average salary, even if the deposit is not paid.

Non-Deduction Service On or After October 1, 1982

— If you have performed creditable civilian service on or after October 1, 1982, during which no retirement deductions were withheld and for which you have not paid a deposit, that service will not be included in computing your annuity. If you have such service, you will be given an opportunity to pay the deposit, with interest, before we complete our action on your application. If you are eligible for and elect an alternative annuity, the deposit will be “deemed” paid.

Reduction for Non-Deduction Service Performed Before October 1, 1982 — An employee who performed creditable civilian service before October 1, 1982, during which no retirement deductions were withheld from salary and for which no deposit has been made will have his or her annual annuity reduced by 10% of the amount due as deposit. The deposit consists of the amount which would have been withheld as retirement deductions, plus interest. Retiring employees who want information on paying such a deposit should attach a signed statement to that effect to the application for retirement. If you are eligible for and elect an alternative annuity, the amount due as deposit for civilian service will generally be “deemed” paid.

b.Refunded Service — Civilian service for which retirement deductions were withheld from your salary and later refunded to you is called “refunded” service. A “redeposit” is a payment to the retirement fund to cover a period of refunded service. Generally, you do not have to make a redeposit if you do not wish to do so. However, this can affect the amount of your monthly annuity.

Refunded Service Which Ended On or After March 1, 1991 — You will receive no credit in the computation of your annuity for the period of refunded service.

This usually results in a reduction in the amount of your annuity, or, in the event of your death, your eligible widow's (or widower's) annuity. The period of service will be creditable for title and average salary purposes whether or not a redeposit is made. If you are eligible for and elect an alternative annuity, the redeposit will be “deemed” paid.

Refunded Service Which Ended Before March 1, 1991 — If you separated from service on or after October 28, 2009, you will receive credit in your annuity computation for the period of refunded service. If you do not pay the redeposit for this service, your annuity will be permanently, actuarially reduced because the redeposit is not paid. The amount of the reduction will be based on factors which will be divided into the amount of redeposit and interest you owe at retirement. Annuities based on separations for disability are not subject to the actuarial reduction and any redeposit due must be paid at retirement. If you are eligible for and elect an alternative annuity, the redeposit will be “deemed” paid.

c.Reduction for Unpaid Post - 1956 Military Service — See the discussion on page 4, instructions for completing Schedule A.

d.Reduction for Early Retirement — Unless retirement is based on disability or under the special provision for law enforcement, firefighter, nuclear materials courier or customs and border protection officer personnel, the annuity of an employee who retires before age 55 will be reduced by 1/6 of 1%

(2% a year) for each full month, if any, under age 55.

e.Reduction for Alternative Annuity — An employee who separates for a non­disability retirement with a life threatening medical condition and a life expectancy of 2 years or less is eligible to elect an alternative annuity benefit. The employee will receive a lump­sum payment of his or her unrefunded retirement contributions, including post­1956 military deposits, and a reduced monthly annuity. Deposits and redeposits that are “deemed” paid are not included as part of the lump­sum payment. The amount of the reduction in annuity is based on the employee's age at retirement and amount of retirement contributions. Employees retiring on disability or who have a former spouse who is entitled by court order to receive a portion of the employee's annuity or a survivor annuity cannot elect an alternative annuity. Married employees must obtain their current spouse's consent in order to elect an alternative annuity.

f.Reduction for Survivor Annuity — This reduction is explained under Section F ­ Annuity Election starting on page 3.

Additional Annuity (Voluntary Contributions) — An employee who, in addition to the amounts withheld from salary, has made voluntary contributions to the retirement fund will be paid, in addition to the regular annuity, $7.00 per year, plus $0.20 for each full year the individual is over age 55 at retirement, for each $100.00 in his or her voluntary contributions account. If, with respect to voluntary contributions, an employee elects a survivor annuity, the additional annuity purchased will be reduced based on the difference between the annuitant's age and the survivor's age as shown in the table on page 3. The survivor's annuity will be 50% of the employee's additional reduced annuity. Note: The additional annuity purchased by voluntary contributions is not increased by cost­of­living adjustments.

Cost-of-Living Increases

1.Limitation on amount of increase. An annuity may not be increased by a cost­of­living adjustment to an amount that exceeds the greater of (a) the maximum pay for a GS­15 thirty days before the effective date of the adjustment or (b) the final pay (or average pay if higher) of the retired employee, increased by the overall annual percentage adjustments (compounded) in General Schedule rates of pay since the employee's retirement.

2.Determination of amount of increase and effective date. Cost­of­living increases are effective on December 1 and are payable in the January annuity payment. They are determined by the percentage increase in the average Consumer Price Index for the "base quarter" of the year in which they are effective over the "base quarter" of the preceding year in which an increase occurred. The “base quarter" is July, August, and September. The first cost­of­living increase you receive will be prorated to reflect the number of months you are on the retirement rolls before the increase is effective.

Payment and Accrual of Annuity

All annuities are payable in monthly installments on the first business day of the month following the one for which the annuity has accrued. All annuities are adjusted to the next lower dollar.

The commencing date of most annuities is the first day of the month after pay ceases and all other requirements for title to annuity are met. There are three exceptions, however:

(1)disability annuities, (2) annuities based on involuntary separations, and (3) annuities based on voluntary retirement of employees who are in pay status for three days or less in the month of retirement. In these three instances, annuities commence no later than the day after pay ceases and all other requirements for title to annuity are met.

Filing Your Application

Submit the completed application to your agency. Your agency must then complete the Agency Checklist of Immediate Retirement Procedures (SF 2801 ­ Schedule D) and Certified Summary of Federal Service (SF 2801­1) which are included in this package. These forms were included in this package so that you would have an opportunity to review and become familiar with the type of information and procedures your agency will need to process your application. After you submit your application, your agency will complete the

SF 2801­1 and return it to you for your review and signature. If you are applying for disability retirement, you and your agency will also need to complete SF 3112. (Be sure to ask your employing agency what documentation and evidence are necessary if you are applying for disability retirement.)

Important: You and your employing agency are jointly responsible for the completeness and correctness of the Certified Summary of Federal Service (SF 2801­1). You should review it carefully before signing it. If you have already signed a summary (for example, during pre­retirement counseling), ask your agency to let you review it again. Any errors, omissions, or discrepancies will delay the processing of your application and may result in incomplete credit for service in the initial adjudication of your application.

What Happens After You File Your

Retirement Application

1.Your Employing Office

Your employing office will close out your records, using the Agency Checklist to assure that all necessary steps are taken. When this process (which includes paying you any unpaid compensation, such as for unpaid annual leave) has been completed, the agency will forward your application and records to OPM.

2.OPM Acknowledgment

Within a few days after receiving your application OPM will send you an acknowledgment. This acknowledgment will show your claim number, which will begin with the letters “CSA.” This number will be very important to you as an annuitant because you will need to refer to it any time you write or call us in connection with your annuity.

Important: OPM cannot begin the processing of your application for retirement until we receive your application and retirement records from your agency. If you need to contact OPM about your application before you receive your retirement (CSA) claim number, contact your former payroll office. Your former payroll office can tell you if your application and records were sent to OPM. If the records were sent, you should provide OPM with the payroll office number and the number and date of the Register of Separations and Transfers on which your retirement package was sent. Only your payroll office can provide this information. Do not contact OPM unless your retirement package has been sent to us.

3.Interim Annuity Payments

The next action OPM takes is a preliminary review of the records available at the time your application is received. If your entitlement to annuity is clear at this point, OPM may authorize interim annuity payments as a means of preventing undue financial hardship while we process your application. These interim payments may be lower than your actual annuity rate. When interim payments are authorized, you will receive a notice showing the amount of your payments.

4.Alternative Annuity (Lump-Sum Refund) Employees who separate for non­disability retirement, have a life threatening medical condition and a life expectancy of 2 years or less are eligible to elect an “alternative” annuity (lump­sum refund of retirement contributions with a reduced monthly benefit). OPM will send you specific information about this election during the processing of your application. If you are retiring because of a disability or if you have a former spouse entitled to court­ordered benefits, you are not eligible to elect an alternative annuity.

5.Disability and Special Retirement Applications Applications for disability retirement and special retirements are processed differently. For disability retirements, your agency will forward your application, evidence supporting your claim of disability, and preliminary records to OPM for disability determination based on review of both medical and non­medical evidence. Interim annuity payments can be authorized only if and after the disability has been approved and your last day in a pay status is known to OPM. For law enforcement, firefighter, air traffic controllers, customs and border protection officers, and nuclear materials couriers, your agency will forward evidence concerning your entitlement to the special provisions. Interim annuity payments can be authorized only if and after OPM has verified your entitlement to the benefit.

6.After Your Application Is Processed

When we finish processing your application, we will send you a booklet explaining your benefits and any monthly survivor benefits payable after your death.

The booklet contains information you will need after you retire, including how to contact OPM to make various changes (tax withholding, address, health benefits, etc.).

What To Do If Your Address Changes

Before Processing Is Completed

If your address changes before you receive your claim number, first contact your agency to find out if your application has been forwarded to OPM.

If your agency has forwarded your application or if you have received your claim number, you can telephone, use email, or write to report your new address. If you know your claim number, please refer to it in any correspondence. If you do not yet have a claim number, please give your name, Social Security number, date of birth, the date of retirement, and the agency you retired from.

You can call OPM at 1­888­767­6738. If you use TTY equipment, call 1­855­887­4957. The Internet address is www.opm.gov/retirement-services. The email address is retire@opm.gov. If you prefer to write to us, you should report your new address to:

U. S. Office of Personnel Management

Attn: Change of Address

P. O. Box 440

Boyers, PA 16017-0440

In addition, you should notify the Postal Service of your forwarding address.

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

No

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

No

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

No

1.Are you eligible to continue Federal Employees Health Benefits coverage as a retiree?

2.Does a court or administrative order require that you provide health benefits coverage for one or more children?

Yes

No

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

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

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

No (Go to item 2)

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

No

1.

Initials

I choose a reduced annuity with maximum survivor annuity (equal to 55% of my basic annuity) for my spouse named in Section E. 1a. 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 your marriage ends by death, divorce, or annulment, this election terminates and you must notify the Office of Personnel Management.

2.

3.

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 type of annuity, complete SF 2801­2, Spouse's Consent to Survivor Election, and attach it to your application. NOTE: This election is not included in determining the 55% maximum for the combined benefit elected for a spouse and former spouse in box 5.

1.Dependent child's name

(first, middle, last)

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

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

3.Disabled

( Ｙ)

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

Yes (Go to item 4a.)

No (Go to Section I.)

4a. Do you want Federal income tax withheld at the rate currently being withheld from your salary?

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

No (Attach a new W-4 form; otherwise, withholding will be at the rate for married with 3 exemptions.)

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.

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 2 or 3, did you attach a copy 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 4, 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 F, did you attach SF 2801­2, Spouse's Consent to Survivor Election?

7.Life Insurance ­ If you answered "yes" to Section D, item 3, did you attach SF 2818, Continuation of Life Insurance Coverage As an Annuitant or Compensationer?

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

9.Tax - If you want to elect a Federal Income Tax withholding rate, did you attach a W­4 form?

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

Yes

No

Not

Applicable

1.Name (last, first, middle)

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

3.Social security number

a.

Branch of service

b.

Serial number

c.Dates of active duty

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. See Schedule A on page 4 of the instructions for the effect on your annuity if the deposit is not paid.)

Yes

No

Yes (complete items 1a - c below)

No (go to question 2)

a.Awaiting OWCP decision

Compensation claim number

b. Claim denied

Yes

No

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)

Part 1 - To Be Completed by the Retiring Employee

Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social security number

General Information: The law requires that a retiring, married employee must elect to provide a survivor annuity for a current spouse, unless the current spouse consents to some other election by signing this form.

A court order which requires a retiring employee to provide a survivor annuity for a former spouse is not an election and spousal consent is not required. In other words, such a court order does not require a current spouse to waive the right to a survivor annuity for the current spouse, even though the Office of Personnel Management must honor the terms of the court order before it can honor the election for the current spouse.

The current spouse may, therefore, receive a smaller annuity than elected or none at all, unless the former spouse loses eligibility for the court­ ordered survivor annuity.

Important: If the current spouse consents to an election to provide no survivor annuity or a partial survivor annuity and is later divorced from the retired employee, the retired employee may not then elect (nor can OPM honor a court order) to provide a former spouse annuity which exceeds the amount elected at retirement for that spouse. This also applies if the parties remarry.

Name (type or print)

Signature (do not print)

Date (mm/dd/yyyy)

(Seal of Notary Public or witnessing authority of person authorized to administer oaths)

(Seal)

Signature (do not print)

Expiration date (mm/dd/yyyy) of commission, if Notary Public

Information for Agency

1.A certified copy of this form must accompany the employee's Application for Immediate Retirement (SF 2801) or an Application for Death Benefits (SF 2800) for a deceased employee if a survivor annuity appears to be payable.

2.This form may also be used:

•for retirement counseling purposes

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

Section A - Identification

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

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.

Federal agency or

military service branch

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

From (mm/dd/yyyy) To (mm/dd/yyyy)

Name of retirement

system*

(e.g., CSRS,

CSRS Offset, etc.)

Remarks and non-creditable time

(Indicate if service is part-time. If service was WAE or intermittent, show the number of days or hours worked.)

Leave

without pay

If basic salary actually earned is available,

make summary entry below:

Signature of Authorized Agency Human Resources Official

Agency name and address, including ZIP Code, area code and telephone number, FAX number, and email address

Official Title

Date (mm/dd/yyyy)

Signature

Date (mm/dd/yyyy)

Signature

Address

Official Title

Submitting Office Number (SON)

Person to contact for further information

Telephone number, FAX number, and email address

Yes

No*

1.

Does the SF 2806 for the applicant named in Section A contain all information necessary to comply with OPM instructions for maintaining the Individual Retirement Record?

5.

If this is a preliminary SF 2806 for disability retirement, is applicant's life insurance status posted?

Signature

Telephone number, FAX number, and email address

Payroll Office Number

Date (mm/dd/yyyy)