Fillable Printable Form RI 10-125

Form RI 10-125

United States

Office of Personnel Management

Retirement & Benefits

Washington, DC 20415

Federal Employee Retirement Coverage Corrections Act (FERCCA)

Election Form

I have read the FERCCA Election Summary material provided to me by .

I have had the opportunity to receive counseling on my options and have received sufficient information to make an

informed decision. I understand my options with regards to the Federal Erroneous Retirement Coverage

Corrections Act (FERCCA), and I therefore, make the following election. I understand this election is final and

irrevocable.

Name (last, first, middle)1. 2. Date of birth (mm/dd/yyyy) 3. Social Security Number

4. Home Address (number, street, city, state, ZIP code)

Enter the agency name

4a. Home telephone number (including area code)

4b. Work telephone number (including area code)

4c. Email address (if applicable)

4. Home Address (number, street, city, state, ZIP code)

Election:

Plan name: _________________________________

Retirement

Plan name: __________________________________

Retirement

Do you have a qualifying court order on file with the Office of Personnel Management that gives a portion of your annuity or survivor annuity to a former spouse?

Yes No

6a. If the answer is yes, a SF 3110, Former Spouse's Consent to FERS Election, needs to be completed by you and your former spouse (notarized). This form

does not need to be completed if (check the appropriate box):

You are legally separated, but there is no divorce decree.

After the divorce, your former spouse remarried before the age of 55 (it does not matter if your former spouse is no longer married.)

You are in CSRS or CSRS Offset and elect to stay in CSRS or CSRS Offset.

You are in FERS and Elects CSRS or CSRS Offset.

Signature Date

This form may be reproduced locally

RI 10-125

May 2010

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