Fillable Printable Form RI 25-49
Fillable Printable Form RI 25-49
Form RI 25-49
Form Approved:
OMB No. 3206-0215
Verification of Full-Time
School Attendance
Show any address change next to your address below.
U.S. Office of Personnel Management
Retirement Surveys & Students Branch
1900 E Street, NW
Washington, DC 20415-3563
Claim number
For Agency Use Only
I II III IV
Student's name Social Security Number
Certification Period Date
Please return the completed form to us within 30 days to avoid interruption of payments for the student.
The Office of Personnel Management is verifying the information you previously provided regarding the full-time attendance of the
student named above. We must be sure that benefits are properly paid and continued eligibility requirements are met. Please have the
verification form on the other side completed and signed by an official of the educational institution the student attended during the
certification period shown above. We request that the student complete Part A and sign the release of information statement below.
This will allow us to obtain any information we need from the school. Please return the completed form in the envelope provided to:
Office of Personnel Management, Retirement Surveys and Students Branch, 1900 E Street, NW, Washington DC 20415-3563 or fax
the form to (202) 606-0022. If the student named above has attended more than one school during the requested certification period,
you may duplicate the verification form for each school as necessary. Please call us at 1-888-767-6738 or (202) 606-0249 if you have
questions.
Part A (To be completed by the student)
1. Did you attend more than one school during the certification period shown above?
No Yes
If yes, you must provide verification from each school.
You may photocopy this form as needed.
2. Do you intend to return to school for the next school year?
No Yes
3. Estimated date of return, if you answered yes to question 2.
4. Student's Phone Number
/ / (
)
-
m m
d d y y y y
5. I authorize the release of information about school attendance to OPM.
6. Student's Signature
7. Date
m m d d y y y y
/ /
8. Email Address
Public Burden Statement
We estimate this form takes an average of one hour per response to complete, including the time for reviewing instructions, getting the needed data, and reviewing
the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of
Personnel Management, Retirement Services Publications Team (3206-0215), Washington, DC 20415-3430. The OMB Number 3206-0215 is currently valid. OPM
may not collect this information and you are not required to respond unless this number is displayed.
RI 25-49
Previous editions are not usable
Revised May 2012
PRINT
SAVE
CLEAR
For greater accuracy in processing this form, please complete the questions in
Part B (To be completed by the school)
a black felt tip or black ink pen.
This form must be completed and signed by an authorized school official. An authorized official of a high school is the principal, vice
principal, assistant principal or equivalent. Above the high school level, the form should be signed by the registrar, dean, administrator, or the
equivalent. At a technical or vocational school, the president, vice president, director, or the equivalent should sign.
1. Did ________________________________________ attend school full-time from ______________ to ______________?
name of the student date (mm/dd/yyyy) date (mm/dd/yyyy)
No, go to Item 2. Yes, go to Item 3.
2. If the student attended school full-time for any period or periods during the school year being verified, please give the
beginning and ending date for each period.
First Period:
Beginning Date Ending Date
/ /
m m
d d y yy y
/ /
m m
d d y yy y
Second Period, if any:
/ /
m m
d d y yy y
Beginning Date Ending Date
/ /
m m
d d y yy y
3. Check the type of educational institution.
High School University/College/Graduate School
Vocational/Trade/Technical Other
4. Name of educational institution
5a. Street Address
5b. City 5c. State 5d. Zip Code
-
6. Phone Number 7. Date
(
)
-
/ /
m m d d y y y y
I certify that all information given in this verification is true and correct to the best of my knowledge and belief. OPM may further verify the
information provided.
8. Signature of School Official
9. Email Address
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, 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.
Reverse of RI 25-49
Revised May 2012
