Fillable Printable Form RI 16-28
Fillable Printable Form RI 16-28
Form RI 16-28
United States
Office of Personnel Management
Direct Payment Program
P.O. Box 979035
St. Louis, MO 63197-9000
Authorization for Direct Payments
Using Pre-Authorized Direct Payments you can pay for life insurance and service credit and make Voluntary Contributions by automatic
deductions from your checking or savings account—without writing a check and mailing your payments. We deduct for life insurance at
the beginning of each month. We deduct service credit and voluntary contributions payments as you specify and mail you a receipt after
each deduction.
Please check one:
New Enrollment Change Enrollment Discontinue Pre-Authorized Direct Payment Service
I authorize the U.S. Office of Personnel Management (OPM), to initiate debit entries to my Checking or
Savings account (select one) indicated below at the depository financial institution named below, hereinafter
called depository, and to debit the same to such account.
For OPM Depository Use Only
Please indicate the payment you are authorizing and give the requested information.
Payment Amount (must
be in multiples of $25.00)
Payment Amount Monthly payment is due the
first day of the month.
This authorization is to remain in full force and effect until OPM has received written notification from me of its termination
in such time and in such manner as to afford OPM and the Depository a reasonable opportunity to act on it. I may revoke my
authorization at any time by providing written notification via a letter or by completing an Authorization for Direct Payments
Form provided by OPM and selecting "Discontinue Pre-Authorized Direct Payment Service" enrollment. The letter or
Authorization Form must be mailed to the address at the top of this form.
Service
Credit
Address (including city, state, & ZIP code) Social Security Number
Bank routing number
Telephone number (including area code)
Branch
Date (mm/dd/yyyy)Signature
Staple voided check from checking account or deposit
ticket or withdrawal ticket from savings account here.
Account number (check only one)
City, state, & ZIP code
Name of your financial institution
Name
Checking
If you need to change the bank account, the payment amount, or the date we deduct monies from
your account, send us another Authorization Form in time for us to receive it at least 14 days
before the regularly scheduled payment date. Mail the form to the address shown above.
Date of Birth (mm/dd/yyyy) Account Number Payment Amount
(minimum of $50.00)
Frequency of Payment:
Life
Insurance
Premium
Voluntary
Contributions
Every Friday
Date of Birth (mm/dd/yyyy) Account Number Frequency of Payment:
Account Number
Savings
Account number
Account number
$D
Date processed
Processed by
First scheduled payment date
If you have questions –
call (202) 606-5240 regarding service credit,
call (202) 606-0706 regarding life insurance,
call 1-888-828-9451 regarding Voluntary Contributions.
This form is available on the OPM website at //www.opm.gov/Forms.
CSA
L
SSN
VC
$
Monthly - specify the day:
Every Friday
Monthly - specify the day:
$
PLEASE KEEP THE BOTTOM COPY OF THIS FORM FOR YOUR RECORDS. RETURN TOP TWO COPIES.
RI 16-28
Previous editions are not usable.
Revised October 2009
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Privacy Act Statement
Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code)
and the Federal Employees Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be
used to identify records properly associated with your application for Federal benefits, to obtain additional
information if necessary, to determine and allow present or future benefits, and to maintain a uniquely identifiable
claim file. The information may be shared and is subject to verification via paper, electronic media, or through the
use of computer matching programs, with national, state, local or other charitable or social security administrative
agencies in order to determine benefits under their programs, to obtain information necessary for determination or
continuation of benefits under this program, or to report income for tax purposes. It may also be shared and
verified, as noted above, with law enforcement agencies when they are investigating a violation or potential
violation of civil or criminal law.
Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number. Furnishing the data
requested is voluntary, but failure to do so may delay or make it impossible for us to process this authorization.
Reverse of RI 16-28
Revised October 2009
