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Fillable Printable Form RI 34-1

Fillable Printable Form RI 34-1

Form RI 34-1

Form RI 34-1

Form approved:
OMB No. 3206-0167
FinancialResourcesQuestionnaire
U.S. Office of Personnel Management
Retirement Operations
GeneralInformation
The purpose of this questionnaire is to determine your eligibility for:
1. waiver of the amount due the retirement system on the basis of
financial hardship;
2. compromise in the amount to be repaid;
3. lower installments; and/or
4. a voluntary repayment agreement.
For more information on waiver, compromise, lower installments, or
voluntary repayment, please refer to our letter or notice informing you of
the overpayment. (Note:If you are only requesting lower installments,
you do not need to fill out this questionnaire as long as your payments will
be (1) at least $50 a month and (2) sufficient to pay off the entire amount
within three years.)
Failure to supply all the requested information may result in an
unfavorable decision. Please note that you may be asked to provide
verification of the information you supply in this questionnaire (e.g.,
evidence of claimed expenses).
To be considered for waiver, compromise, lower installments, or a
voluntary repayment agreement, you must complete and return this
questionnaire to us within 30 days after the date shown in the notice of
overpayments.
GeneralInstructions
1. Please read all items carefully.
2. Type or print in ink.
3. Complete all items on the form. If a question does not apply, answer
“No” or “None”. Do not leave it blank. If answers require additional
space, continue them in Section X. Attach additional sheets if
necessary. Include your name and retirement claim number in the
upper right corner of each additional sheet.
4. Sign and date this questionnaire in Section XI.
5. Send the completed form to:
Office of Personnel Management
Attn: Funds Management
P.O. Box 7125
Washington DC 20044-7125
DetailedInstructions
Most of the questionnaire items are self-explanatory. Instructions are
provided below for those items identified with an asterisk(*), which
require further explanation.
Section I - Personal Data
Item 1 Give the name of the former Federal employee upon whose
service your entitlement to retirement system benefits was
based. (If the benefits are based upon your own service, give
your name.)
Section IV - Average Monthly Income
Item 1 Enter your current monthly gross salary - i.e., wages, fees,
commissions - for yourself and then your spouse. (Enter the
total
salary paid beforeany payroll deductions are made; e.g.,
Federal, state, and local taxes; social security taxes; insurance,
etc.). If your salary fluctuates on a monthly basis, estimate the
monthly average.
Item 6 Enter all other current income not listed. This may include
unemployment compensation, public assistance benefits, trust
income, tax refunds, alimony, child support, royalties,
payments of debts owed to you, income provided by
dependents listed in Section I (other than spouse), etc. Estimate
the average monthly amount.
Section V - Average Monthly Expenses
Item 1 Enter the amount you currently spend on average for rent,
mortgage, homeowner/condominium fees, etc., each month. If
you include property taxes in this item, do not include them in
V.9.
Item 3 Enter the average monthly amount you spend for electricity,
telephone, gas, water, coal, oil, etc.
Item 4 Enter the average monthly amount you spend for household
maintenance (repairs, cleaning supplies, etc.) and personal
necessities.
Item 7 Enter the average monthly amount you spend for insurance
(life, health, accident, automobile, homeowners, etc.). Do not
include homeowner’s insurance if it is already included in item
V.1.
Item 8 Transportation costs include necessary automobile expenses
(gas, oil, maintenance), cab fares, and public transportation.
Item 9 Enter 1/12 of all taxes you pay in a year, including Federal,
state, and local taxes; property taxes not included in item V.1;
sales taxes not included in other items, etc.
Item 10 Enter the total amount due monthly from existingliabilities as
shown in Column E of Section VII. (This amount should not
include any expenses - such as mortgage payments - listed
under other items in Section V.)
Item 11 Other living expenses which you can prove to be ordinary and
necessary. Provide a breakdown of these expenses in Section
X.
Section VIII - Assets
Item 4 Enter the cash value of your money market accounts,
certificates of deposit, etc. Do not include Individual
Retirement Accounts (IRA’s) or other interest bearing accounts
which belong in item 6.
Item 5 The current value on any stocks or bonds you own. The current
value is the amount you would receive if you sold these
securities.
Item 6 The current value of any IRA’s, Keoughs or similar retirement
savings accounts.
Item 8 Identify any automobiles, vans, trucks, motorcycles, motor
homes (RV’s), trailers, campers, boats, etc., that you own, and
their resale value (the amount you would receive if you sold
these vehicles). Any remaining liabilities for these vehicles
should appear in Section VII.
Item 9 The resale value of your home and other real estate. (If you
own two or more properties, list separately. Also show the
unpaid amount of any real estate mortgages in Section X.)
Item 10 The current resale value of any other personal property (art
pieces, jewelry, etc.) which can be sold and which are valued in
excess of $1,000 per item. (Itemize in Section X.)
RI 34-1
Revised May 2012
Previous edition is usable
Financial Resources Questionnaire
For Consideration in Connection With Collection of an Overpayment
Please read the attached instructions and Privacy Act Statement before completing this form.
Section I - Personal Data
*1. Name of former Federal employee (Last, first, middle) 2. Claim number
Former Federal employee's date of birth
(mm/dd/yyyy)
3.
4. Your name5. Your date of birth (mm/dd/yyyy) 6.
Your social security number
7. Your address
Your telephone number (including area code)
8.
Your email address
9.
10. Your dependents (list spouse first):
Name (Last, first, middle)
Relationship
Date of Birth
Social Security Number
Section II -Your Current/Most Recent Employment Section III -Spouse's Current/Most Recent Employment
1. Current or most recent position 2. Dates of employment
(e.g., Salesclerk)
From (mm/yyyy) To (mm/yyyy)
3. Name and address of employer
Section IV -Average Monthly Income
1.
Current or most recent position
2.
Dates of employment
(e.g., Salesclerk)
From (mm/yyyy) To (mm/yyyy)
3. Name and address of employer
Section V -Average Monthly Expenses
Type of Income
*1. Gross salary or wages
(before payroll deductions)
Your Income
$
Spouse's Income
$
2. Self- employment (net)
3. Gross retirement benefits:
Military retired or retainer pay
Social Security
Payments from OPM
Other (specify)
4. Disability benefits
(Veterans benefits, Workers'
Compensation, etc.)
5. Investments
(interest, dividends, rental income,
etc.)
*6. Other (itemize in Section X)
7. Total average monthly income
(add items 1 thru 6)
$ $
Type of Expense
Rent/mortgage payments,
homeowner/condominium fees
*1.
Monthly Average
$
2. Food
*3. Utilities
*4. Household maintenance
5. Clothing
6.
Medical and dental
(non-reimbursable)
*7. Insurance premiums
*8. Transportation
*9. Taxes (1/12 of all yearly taxes)
*10. Monthly payments on existing installment
contracts and other debts
(Total from Section VII)
*11. Other ordinary and necessary living expenses
12.
Total average monthly expenses
(add items 1 thru 11)
$
*See "Detailed Instructions" for an explanation of this item.
RI 34-1
Previous edition is usable Revised May 2012
Section VI - Summary
1. Total Monthly Income
(Section IV, line 7, combined)
$
4. How much of the balance in item 3 can you apply toward
repayment on a monthly basis?
$
2. Total Monthly Expenses
(Section V, line 12)
-
5.
If your monthly expenses exceed your monthly income, how do you pay the difference?
3.
Balance
(Subtract line 2 from line 1 above)
$
Section VII - Installment Contracts and Other Debts
Show here all debts which you are required to pay in regular monthly installments, such as car, television or appliance payments to dealers, banks, or financial companies;
repayment of money borrowed for any purpose; charge accounts and credit card payments; doctor or hospital bills; taxes owed; etc. Do not include expenses (such as mortgage
payments) already listed in Section V, exclusive of item 10. Note: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay
in Section X.
(A) Name and Address of Creditor (B) Purpose of Debt
(C) Original
Amount of Debt
(D) Unpaid
Balance
(E) Amount
Due Monthly
(F) Scheduled Date
of Full Repayment
$ $ $
Total
$ $ $
Section VIII - Assets
*9.
Resident real property & other real property owned
(itemize below or in Section X)
Type of Vehicle Make Model Year Resale Value
Type of Asset Value ValueType of Asset
$
1.
Cash on hand
Checking account(s). Give name and address of
financial institution(s) below
2.
Savings account(s). Give name and address of financial
institution(s) below
3.
Other interest-bearing account(s)
*4.
Stocks, bonds, and other securities
(itemize below or in Section X)
*5.
Individual Retirement Accounts
*6.
$
Debts owed to you (give name of debtor)
7.
*8. Vehicles
Total assets (total of lines 1 thru 10)11.
*10.
Other assets (itemize in Section X)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
*See "Detailed Instructions" for an explanation of this item.
If "Yes", give details in Section X.
Is there any likelihood that you will receive an inheritance or benefits from a trust?
NoYes
Warning
Any intentionally false statement, concealment of material fact or
willful misrepresentation relative to this questionnaire is
punishable by a fine of not more than $10,000 or imprisonment
for not more than 5 years, or both (18 U.S.C. 1001). You may be
asked to furnish verification of any statement you make.
Use this space and additional sheets if necessary to supply any other pertinent information and to continue your answers to previous items. Indicate section and item number to
which your comments apply.
Section IX - Additional Data
Is anyone holding money or assets on your behalf?1.
Do you have any of the incorrectly paid checks in your possession?
(If "Yes", show the total amount and return the checks immediately.)
2.
3.
Section X - Remarks
Section XI - Certification
I affirm that the information provided herein is true, correct, and complete to the best of
my knowlegde and belief.
Your signature1.2.Date (mm/dd/yyyy)
The Office of Personnel Management (OPM) administers the Civil Service Retirement System and the Federal Employees Retirement System for Federal employees as
authorized by chapters 83, 84, 87, and 89 of title 5, U.S. Code, and Public Laws 83-589, 84-356, and 86-724. The Federal Claims Collection Act of 1966 as amended (Public
Law 89-508) empowers the head of a Federal agency to enforce collection of claims for the United States of money or property arising out of the activities of the agency. Section
179.102 of title 5, Code of Federal Regulations, delegates authority to the Associate Director for Retirement and Insurance for collection of claims arising out of overpayment of
Federal retirement benefits. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a social security number or tax
identification number. This is an amendment to title 31, Section 7701. The information requested on this form is needed to evaluate your financial ability to repay OPM. The
information may be shared with the General Accounting Office and the United States Department of Justice in the event litigation is required to enforce collection. This
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. Provision of the information is voluntary; however, failure to supply all requested information may result in a thorough
financial investigation or a decision adverse to you. Pending the results of the investigation, evidence may be turned over to the Department of Justice for appropriate action.
Intentionally false statements and/or suspected illegal activities are reportable to the appropriate law enforcement agencies.
We estimate this form takes an average 60 minutes 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
(OPM), Retirement Services Publications Team (3206-0167), Washington, D.C. 20415-3430. The OMB number, 3206-0167, is currently valid. OPM may not collect this
information, and you are not required to respond, unless this number is displayed.
Public Burden Statement
Privacy Act Statement
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