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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