Fillable Printable Form RI 20-064
Fillable Printable Form RI 20-064
Form RI 20-064
Form Approved:
U.S. Office of Personnel Management
OMB number: 3206-0235
Civil Service Retirement System
Boyers, PA 16017
Date
Civil Service Claim Number
CSA
File Reference
This is in response to your request for information on providing a survivor annuity for your former spouse. You must file a new former
spouse survivor annuity election after your divorce or annulment — even if you had already elected a survivor annuity for that individual as
a current spouse at the time of your retirement. The election that you made at retirement is no longer effective after your divorce or
annulment. If you fail to inform OPM that your marriage ended by divorce or annulment and fail to make a new former spouse survivor
annuity election after your divorce or annulment, the fact that your annuity continues to be reduced to provide a current spouse survivor
annuity will not entitle your former spouse to a survivor annuity after your death. Please read the enclosed pamphlet and the information
below carefully before making your election.
A. Filing Time Limit: You must file your election (a) within 2 years after the date your marriage to the former spouse ended by divorce or
annulment or (b) within 2 years after the date another former spouse lost entitlement to a survivor annuity benefit for which your annuity was
reduced as explained in Chapter IX of the pamphlet.
3. The above reductions to provide a survivor benefit will reduce your gross monthly annuity to $__________.
2. If applicable, there will be two reductions in your annuity to provide the survivor benefit. The first reduction is $__________ for the
regular cost of the survivor benefit. This reduction may stop if your former spouse loses entitlement. The second reduction represents the
amount your annuity would have been reduced for the survivor benefit (plus interest) since your retirement. As of
_____________________
this amount is $__________ and the monthly reduction to pay it back is $__________. This reduction is permanent; it will NOT stop if your
former spouse loses entitlement. The reductions in your annuity may increase if you delay your election.
1. Your current gross monthly annuity rate is $__________.
B. If You Elect The Maximum Survivor Benefit Available For Your Former Spouse: Your annuity will be adjusted as explained
below. Please see Part IV of the pamphlet for additional information.
4. Your former spouse's gross monthly survivor annuity rate including all cost-of-living adjustments (COLA's) since your retirement will be
$__________. Future COLA's will be applied to this rate. This is the maximum survivor benefit now available for your former spouse.
C. Filing Instructions: If you want to provide the maximum available survivor benefit, please complete the election form and return it to
the U.S. Office of Personnel Management, Retirement Operations Center, ATTN: PRM-STOP, P.O. Box 45, Boyers, PA 16017-0045 within
the filing time limit. See Part IX of the enclosed pamphlet for information on the documents you may need to submit with your election.
I request information on providing a former spouse annuity of $__________ per month. (Specify a whole dollar amount.)
D. If You Want To Elect A Smaller Survivor Benefit: The reduction in your annuity will be smaller, in rough proportion to the smaller
survivor benefit you elect. If you want to know the exact cost before you make your election, do not complete the election form. Instead,
please specify
below the monthly amount you want your former spouse to receive, provide your signature and date, and return this letter to
the address shown in Part C above. We will then provide you with the information and send you another application.
Signature Day time telephone number Date (mm/dd/yyyy)
Enclosures: RI 20-64A, Former Spouse Survivor Annuity Election
Signature of Administrative Legal Specialist, (724) 794-2005
RI 20-64B, Information on Electing a Survivor Annuity for Your Former Spouse
RI 20-64
Previous editions are not usable.
Revised August 2005
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