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Fillable Printable Form RI 25-14

Fillable Printable Form RI 25-14

Form RI 25-14

Form RI 25-14

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Form Approved: OMB No. 3206-0032
Self-Certification of Full-Time School
Attendance For The School Year:
Show any change of address
on this form below:
U.S. Office of Personnel Management
Retirement Surveys & Students Branch, Washington, DC 20415-3563
A
F
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000000000
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1. Student's name and date of birth
For Agency Use Only
I
II III IV
Claim number
2. Currently certified thru Date
IMPORTANT: Please read the enclosed instruction sheet before completing this form. To avoid interruption of payments, please complete this form
immediately, using a pencil and darkening the entire oval; so our computer can process your form without delaying your payments. Please complete this
form for the entire school year (not just one semester) if plans are known; and complete it for one school year only. Please do not take this form to the
school. The person in the address above must sign in item 17. This is a personalized form, precoded for only the student shown in item 1.
Items 7 - 16 must be completed if the student
returned or will return to school full-time on
or after the date shown in item 2 above.
3. Is the student's date of birth correct as shown in item 1 above?
No. Show the correct date below and
attach a birth certificate.
Month
Day
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00
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6. During the past 12 months, did the student stop school before the end
of the school term, or change from full-time to part-time status?
Month
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
5. Is the student currently married?
No Yes. Show the
marriage date below.
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Month
Social Security Number
4. Student's Social Security Number
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Yes. Show date full-time attendance ended.
Yes
Year
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7. Show the school's name and address
(including ZIP code):
Phone number (if available & area code):
( )
8. Is this school accredited by a nationally
recognized
accrediting agency or
association?
No
No Yes
Year
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JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Year
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Previous editions are not usable
RI 25-14
Revised June 2011
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9. Enter the date the student began or will begin
10. Enter the date this school attendance will
11. Is the date given in item 10 the end of
full-time school attendance for the school year
end or ended. If the student plans to attend
the school year?
you are certifying. Date should be on or after date
for the full school year, you should show the
shown in item 2.
ending date of the full school year (NOT the
Yes No
semester). This date must be later than the
Month Day Year
JAN
0000
FEB
1111
MAR
2222
APR
3333
MAY
444
JUN
555
JUL
666
AUG
777
SEP
888
OCT
999
NOV
DEC
13. Enter the estimated date the student will
begin full-time attendance for the NEXT
school year after the school year shown
in items 9-10.
Month Year
JAN
00
FEB
11
MAR
22
APR
33
MAY
44
JUN
55
JUL
66
AUG
77
SEP
88
OCT
99
NOV
DEC
16. Is the student in a school-sponsored co-op
or internship program?
Yes (Attach a letter from the school
explaining the program.)
No
date shown in item 9.
Month Day Year
JAN
0000
FEB
1111
MAR
2222
APR
3333
MAY
444
JUN
555
JUL
666
AUG
777
SEP
888
OCT
999
NOV
DEC
14. Type of School shown in item 7.
High School
Trade/Technical/or Vocational
Jr. College/College/
Community College/or University
Other: Indicate type of school
12. Does the student intend to return to school full-time
after the date shown in item 10, with less than a 5
month break?
Undecided
No
Yes. Show the beginning date of
the next school year in item 13.
15. Attendance for School shown in item 7.
Mark only one (A or B) below
A: Classroom Hours B: Credit Hours such
per week, such as for as for college.
High Schools or trade
schools. (Combine
work/study hours if
in a high school work
study program.)
Total Hours
Total Hours
00
00
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2222
3333
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555
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WARNING: Any intentionally false statements or willful misrepresentations are punishable by fine,
imprisonment, or both (18 USC 1001).
17.
I certify that all information given in this certification is true and correct to the best of my
knowledge and belief. I understand that I must immediately notify the Office of Personnel
Management (OPM) if the student transfers to another school, discontinues school
attendance, reduces attendance to less than full-time, marries or dies. I agree to return all
overpayments of student benefits, including overpayments that may be made after I notify
OPM of any terminating event. I authorize the appropriate school official to verify my school
attendance status to OPM in the manner requested by OPM (e.g., by telephone, fax, email, or
written correspondence).
Email address
Signature of payee (person who is receiving the payments)
Email address
Signature of student
Daytime telephone number (including area code)
( )
Date (month/day/year)
Reverse of RI 25-14
Revised June 2011
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