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Fillable Printable Form RI 92-19

Fillable Printable Form RI 92-19

Form RI 92-19

Form RI 92-19

Application for Deferred or Postponed Retirement
Form Approved:
OMB number 3206-0190
Federal Employees Retirement System
This application is for you if you are a former Federal employee who was covered by the Federal Employees Retirement System (FERS) and you wish to
apply for your retirement annuity. You should complete this application if you choose to apply for an annuity which will begin more than 1 month after
your separation from Federal service (or transfer to a position not covered by FERS) and:
1. you have completed at least 5 years of creditable civilian service and are eligible for a deferred retirement at age 62; or
2. you have completed at least 10 years of creditable service, including 5 years of civilian service, and are eligible for an annuity at the
Minimum Retirement Age (MRA).
Send your completed application (approximately 60 days before you want your benefits to begin) to:
Office of Personnel Management
Federal Employees Retirement System
P.O. Box 45
Boyers, PA 16017-0045
You should have received the informational pamphlet RI 92-19A, Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement
System, with this application. If you did not receive this pamphlet, you can access the pamphlet on our website at www.opm.gov/Forms/. You can also get a
copy by calling the Office of Personnel Management (OPM) at 1-888-767-6738 or by contacting us at the address above. If you use TTY equipment, call
1-855-887-4957.
If your address changes before you receive your claim number, write to us giving your name, date of birth and social security number. If you have received
your claim number, remember to refer to it.
Instructions for Completing Application for
Deferred or Postponed Retirement
Type or print clearly. If you need more space in any section, use
a plain piece of paper with your name, date of birth, and Social
Security Number written at the top. If you do not know an answer
write “unknown.” If you are uncertain of any information you provide,
answer to the best of your ability, followed by a question mark (?).
The following information should help you to answer the questions on
the application which are not self-explanatory.
Section A - Identifying Information
Item 2: List other names under which you have been employed
in the Federal government (such as a maiden name).
This will help us to locate and identify all your records.
Item 4: Enter the address to which correspondence should be
mailed. Do not enter the bank address where your payments
will be deposited here; complete Section H of this
application.
Section B - Federal Civilian Service
Item 2: Show the agency where you performed your last Federal
service. Give the bureau and/or division as well as the name
of the agency and include its location (city, state).
Item 3: List all Federal civilian service that you have performed.
Give the bureau and/or division as well as the name of the
agency, along with the agency’s location and the beginning
and ending dates of the service.
Previous editions are not usable
Section C - Military Service
Item 1: Indicate whether you have performed active duty that terminated under
honorable conditions in the armed services or other uniformed services
of the United States, including the following:
Army, Navy, Marine Corps, Air Force or Coast Guard
of the United States.
Cadet at the United States Military Academy, United States Air
Force Academy, United States Coast Guard Academy, or
Midshipman at the United States Naval Academy.
Regular Corps or Reserve Corps of the Public Health Service after
June 30, 1960.
Commissioned Officer of the National Oceanic and Atmospheric
Administration after June 30, 1961 or a predecessor entity in
function.
Excluding the National Guard, active service in the reserve
components of the uniformed services, including active duty for
training, is military service. Service as a National Guard member does
not meet the definition of military service for purposes of civil service
retirement, except when the member is ordered to active duty in the
service of the United States or performs full-time National Guard duty
(as such term is defined in section 101(d) of title 10) if the National
Guard duty interrupts creditable civilian service under subchapter I of
chapter 84 of title 5, and is followed by reemployment in accordance
with chapter 43 of title 38 that occurs on or after August 1, 1990.
Instruction Page 1, RI 92-19
Revised May 2012
Item 2: Persons who performed active military service after
December 31, 1956, must have paid a deposit to receive
credit under the Federal Employees Retirement System
(FERS) for their military service. You must have paid your
deposit to your former employing agency. If you did not pay
your deposit while you were still a Federal employee, you
cannot pay it now. If you have military service performed
after 1956, which is covered by a deposit you paid as an
employee, check “Yes” and continue with this section. Items
2a and 2b will help us locate records of your payment.
Item 4: Indicate whether you are receiving or have applied for
military retired or retainer pay (including disability retired
pay and reserve retainer pay.)
If you are receiving military retired pay, your military
service cannot be used for retirement purposes unless your
retired pay was awarded because of a service-connected
disability incurred in combat with an enemy of the United
States or caused by an instrumentality of war and incurred
in the line of duty during a period of war as defined by
Section 1101 of title 38, or was awarded under Chapter
1223, title 10, formerly Chapter 67, title 10 and title III
of Public Law 80-810 (reserve retired pay at age 60 based
on 20 years of active and reserve service). Otherwise, to
receive credit for your military service, you must waive
your military retired pay.
To waive military retired pay for FERS retirement purposes,
send a written request, specifying the effective date of the
waiver and your Social Security Number, directly to the
Military Finance Center from which you receive retired pay.
Attach a copy of your letter to this application. You should
mail this letter at least 60 days before your annuity will
begin. Your letter might say, “I, (full name, military serial
number, and Social Security Number), hereby waive my
military retired pay for FERS retirement purposes, effective
close of business (specify the day before annuity begins).”
If you wish, add “I authorize the Office of Personnel
Management to withhold from my retirement annuity any
amount of military pay granted beyond the effective date of
this waiver due to any delay in receiving or processing this
election.” This authorization may hasten the processing of
your waiver and your retirement application.
If you have already waived military retired pay in order
to receive credit for your active military service for FERS
retirement purposes, attach a copy of your request for
waiver and of any reply you have received.
Obtain counseling from the military before waiving military
retired pay for FERS retirement if you receive or may
receive Combat Related Special Compensation (CRSC) or
concurrent receipt of military retired pay and veterans
compensation.
Reminder: Even if you have waived military retired pay or
qualify for one of the exceptions to waiver, you must have
paid a military deposit for your military service performed
after 1956 to receive credit for the service in your FERS
annuity, and the military deposit must have been paid to
your employing agency before you separated from FERS
covered Federal employment.
Section D - Other Claim Information
Item 3: If you have applied for or have ever received workers’ compensation
from the Office of Workers’ Compensation Programs (OWCP), U.S.
Department of Labor, because of a job-related illness or injury, check
the “Yes” box and furnish your claim number(s), type(s) of benefits,
and date(s) of benefits in 3a, 3b and 3c.
The information requested regarding benefits from the OWCP is
needed because the law prohibits payment of both FERS retirement
annuity and compensation for total or partial disability under the
Federal Employees’ Compensation Act at the same time. In some
cases, credit for service, particularly for periods of leave without pay,
may also be affected.
Section E - Marital Information
Item 2: Indicate whether you have a living former spouse to whom
a court order awards a survivor annuity or a portion of your retirement
benefits based on your Federal employment. If you answer “Yes,” you
must submit a copy of the divorce decree and any attachments or
amendments.
Section F - Annuity Election
Read the information about survivor benefits and their associated cost found in
the pamphlet “Applying for Deferred or Postponed Retirement Under the Federal
Employees Retirement System” (RI 92-19A) before completing Section F.
To be eligible for a survivor annuity after your death, your widow(er) must have
been married to you for a total of at least 9 months or be a parent of your child.
The marriage duration requirement does not apply if your death is accidental.
Survivor elections terminate upon the death of the person elected. An election of a
survivor annuity for a current spouse in box 1 or 2 also terminates upon a divorce
from that spouse. An election of a survivor annuity for a former spouse in box 5
also terminates if that former spouse remarries before age 55, unless the annuitant
and the former spouse were married for 30 years or more. You must notify us
when one of those events terminating a survivor election occurs. Also notify us if
a former spouse who is entitled to a survivor annuity under a court order accept-
able for processing becomes ineligible for the former spouse annuity because of a
reason specified in the court order or because of a remarriage prior to age 55.
Please note that, in accordance with the law, both a survivor annuity election
made at retirement and survivor annuity election made before a divorce, terminate
upon death or divorce and the annuitant must make a new election (reelection)
within 2 years after the terminating event to provide a survivor annuity for a
spouse acquired after retirement or for a former spouse. Continuing a survivor
reduction, by itself, is not effective to reelect a survivor annuity for a spouse
married after retirement or for a former spouse.
Item 4: If you initial box 4, a person selected by you at retirement who has an
insurable interest in you, will receive a survivor annuity upon your
death. Enter the requested information about that person. Insurable
interest exists if the person named (such as a close relative) may
reasonably expect to derive financial benefit from your continued life.
You must provide documentation that you are in good health in order
to choose this type of annuity. You will be notified of the additional
evidence required.
If you choose this type of annuity, the amount of the reduction in your
annuity will depend upon the difference between your age and the age
of the person named as survivor annuitant, as shown in the following
table. The survivors rate will be 55% of your reduced annuity.
Reverse of Instruction Page 1, RI 92-19
Revised May 2012
Age of the Person Named
in Relation to That of
Retiring Employee
Reduction in
Annuity of
Retiring
Employee
Older, same age, or less than 5 years
younger
10%
5 but less than 10 years younger
15%
10 but less than 15 years younger
20%
15 but less than 20 years younger
25%
20 but less than 25 years younger
30%
25 but less than 30 years younger
35%
30 or more years younger
40%
You may elect this insurable interest survivor annuity in
addition to a regular survivor annuity for a current or former
spouse. However, if you elect an insurable interest annuity
for your current spouse, you must both jointly waive the
current spouse annuity. Generally, an insurable interest
annuity cannot be cancelled. However, if you elect an
insurable interest annuity for your current spouse because a
former spouse is entitled to the regular survivor annuity
(under a court order acceptable for processing or based on
your election of that survivor benefit for the former spouse),
you can convert the insurable interest election for your
current spouse to a current spouse annuity within two (2)
years of the former spouse losing entitlement to the regular
survivor annuity.
Item 5: If you initial box 5, your former spouse(s) will receive a
survivor annuity upon your death. The maximum survivor
annuity payable to your former spouse(s) is 50% of your
unreduced annuity. Your annuity will be reduced 5% or
10% according to the total benefit you want to provide.
If you are married and initial box 5, you must complete and
attach Schedule A - Spouse’s Consent to Survivor Election,
to your application. The law requires consent of the spouse
if a married person elects a full or partial survivor annuity
for a former spouse. You may not elect a combined benefit
for your current and former spouse(s) which exceeds 50%
of your benefit.
Section G - Information About Children
Complete Section G by providing the names and dates of birth of your
unmarried dependent children under the age of 22. Also list any child
over the age of 22 who is incapable of self-support because of mental
or physical disability incurred before the age of 18. Check the box
headed “disabled” by the name of each child to whom this applies.
Information about your children in your annuity claim file may help
to expedite the processing of claims for survivor benefits when you
die.
Section H - Payment Instructions
Complete in all cases.The U. S. Department of the Treasury pays all Federal benefit
payments electronically. Most Federal payments are paid by Direct Deposit into a
savings or checking account at a financial institution. If you do not have a bank
account, or prefer not to have your annuity payments deposited directly to your
bank account, you can choose a Direct Express debit card. If you choose this
option, your annuity payment will be automatically deposited to the Direct
Express card on the payment date. To obtain a debit card, go to www.godirect.org
or call 1-800-333-1795. If your payments are not electronically deposited to your
account and you do not have a Direct Express card, you must contact the
Department of Treasury at 1-800-333-1795.
You cannot receive your annuity payments by direct deposit or the Direct Express
debit card program if your permanent payment address is outside the United
States in a country where these programs are not available.
Item 2: You may obtain your Financial Institution Routing Number by calling
your bank, credit union, or savings institution. This number is very
important. We cannot pay by direct deposit without it. We suggest you
call your financial institution to verify this number.
If you prefer, you may attach a cancelled personal check that shows the
information requested instead of filling in the requested financial institution
information. If you attach your personal check, it is especially important that
you contact your bank, credit union, or savings institution to confirm that the
information on the check is correct information for direct deposit. (Some
financial institutions, especially credit unions, use different routing numbers on
checks.) We can then use this information to start paying you by direct deposit.
Section I - Applicant’s Certification
Be sure to sign (do not print) and date your application after reviewing the
warning.
Schedules (Attachments)
There are three schedules attached to this application for deferred or postponed
retirement. Some of these schedules may apply to you and some may not. Read
the following to determine which schedules you should complete. Instructions for
completing and information about each follows.
Schedule A - Spouse’s Consent to Survivor Election
Complete this schedule if you are married and, in Section F, you do not elect box
1, a maximum survivor annuity for your spouse. For any other election you must
obtain your spouse’s consent. (See the pamphlet entitled “Applying for A
Deferred or Postponed Retirement Benefit Under the Federal Employees
Retirement System(RI 92-19A) for information about asking the Office of
Personnel Management (OPM) to waive the spousal consent requirement in
special circumstances.)
Instruction Page 2, RI 92-19
Revised May 2012
Part 1: You must complete this section. Include your name, date
of birth and social security number as shown on your
application. Check the box(es) that corresponds to the
selection(s) you made in Section F on your application.
Check all boxes that apply.
Part 2: Your spouse completes this section, in the presence of a
notary public.
Part 3: A notary public or other person authorized to administer
oaths (e.g., a justice of the peace) must complete this
section, after witnessing your spouse’s signature.
SchedulesB&C-For Applicants Who Have At Least 10
Years of Creditable Service
If you have at least 10 years of creditable service (5 of which must be
civilian) which will be used to compute your benefit, then you must
complete one of these two schedules. Do not complete either of these
schedules if you have less than 10 years of service.
Complete Schedule B if you had attained the Minimum Retirement
Age (MRA) when you left Federal service and had at least 10 years of
creditable service. You are eligible to choose when you want your
benefit to begin and may be eligible to reenroll in the health benefits,
life insurance and Federal Dental and Vision programs and carry them
into retirement.
Complete Schedule C if you had not yet attained the MRA when you
left Federal service, but you did have at least 10 years of creditable
service. You are eligible to choose when you want your benefit to
begin.
The MRA is based on the year of your birth and determines the earliest
date you became eligible to have your retirement annuity begin. The
Minimum Retirement Age Schedule is:
If your year of birth is: Your MRA is:
Before 1948
55 years
1948
55 years, 2 months
1949
55 years, 4 months
1950
55 years, 6 months
1951
55 years, 8 months
1952
55 years, 10 months
1953 to 1964
56 years
1965
56 years, 2 months
1966
56 years, 4 months
1967
56 years, 6 months
1968
56 years, 8 months
1969
56 years, 10 months
After 1969
57 years
Schedule B
Part 2: You may choose to have your annuity begin on:
1. the first day of the month following your separation from
Federal service; or
2. the first day of any month which is at least 31 days after the
Office of Personnel Management (OPM) receives your
application for retirement (but before your 62nd birthday).
Your annuity will be reduced by 5/12 of 1% for each full
month (5% per year) that the date your annuity begins
precedes your 62nd birthday. You can avoid the age reduction
entirely if you choose the first day of the month that you reach
age 62 as your annuity commencing date. The age reduction
does not apply if your annuity commences the first day of the
month after your 60th birthday and you have at least 20 years
of service.
Parts 3 People who leave Federal service after reaching the MRA with at least
and 4:
10 years of creditable Federal service are eligible to reenroll in the
Federal Employees Health Benefits Program and the Federal
Employees’ Group Life Insurance Program if they had participated in
the program for the 5 years of service immediately before their
separation date or continually from their earliest opportunity. If you
were enrolled in either of these programs when you left Federal
employment and you had already attained your MRA and had 10 years
of creditable service, complete these sections. If you want information
about reenrolling in either program, indicate so in item 1b.
Part 5: People who leave Federal service after reaching the MRA with at least
10 years of creditable Federal service are eligible to reenroll in the
Federal Dental and Vision Insurance Program (FEDVIP). If you were
enrolled in FEDVIP when you left Federal employment and you had
already attained your MRA and had 10 years of creditable service,
complete this section. If you want information about reenrolling,
indicate so in item 1b.
Part 6: If you are enrolled in the Federal Long Term Care Insurance Program
(FLTCIP), your coverage will continue. No action is required by you.
However, you may choose to have your premium payments deducted
from your annuity. To elect annuity deduction of premiums, please call
Long Term Care Partners, at 1-800-582-3337 (TTY: 1-800-843-3557).
If you are not currently enrolled in the FLTCIP, you, your spouse, and
your adult children may apply for FLTCIP coverage provided you are
eligible for a deferred or postponed annuity. You may request an
application by calling Long Term Care Partners, at 1-800-582-3337
(TTY: 1-800-843-3557), or by visiting www.ltcfeds.com.
Schedule C
Part 2: You may choose to have your annuity begin on:
1. the first day of the month following the month in which you
reach your MRA; or
2. the first day of any month which is at least 31 days after OPM
receives your application for retirement if you have reached
your MRA (but before your 62nd birthday).
Reverse of Instruction Page 2, RI 92-19
Revised May 2012
Your annuity will be reduced by 5/12 of 1% for each full
Part 3: If you are enrolled in the Federal Long Term Care Insurance Program
month (5% per year) that the date your annuity begins
(FLTCIP), your coverage will continue. No action is required by you.
precedes your 62nd birthday. You can avoid the age
However, you may choose to have your premium payments deducted
reduction entirely if you choose the first day of the month
from your annuity. To elect annuity deduction of premiums, please call
that you reach age 62 as your annuity commencing date.
Long Term Care Partners, at 1-800-582-3337 (TTY: 1-800-843-3557).
The age reduction does not apply if:
If you are not currently enrolled in the FLTCIP, you, your spouse, and
a) Your annuity commences the first day of the month
your adult children may apply for FLTCIP coverage provided you are
after your 60th birthday and you have at least 20
eligible for a deferred or postponed annuity. You may request an
years of service, or
application by calling Long Term Care Partners, at 1-800-582-3337
b) Your annuity commences the first day of the month
(TTY: 1-800-843-3557), or by visiting www.ltcfeds.com.
after you reach your MRA and you have at least 30
years of service.
Privacy Act and Public Burden Statement
Solicitation of this information is authorized by the Federal Employees Retirement System law (Chapter 84, title 5, U.S. Code). The data
furnished will be used to determine the type of annuity awarded. 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 to determine and issue benefits under those programs. It may also be shared and verified, as noted above, with law
enforcement agencies when they are investigating a violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes
use of the Social Security Number as an individual identifier to distinguish between people with the same or similar names. Failure to furnish
the requested data may delay or prevent action on the retirement application.
We estimate that this form takes an average of 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
(3206-0190), Washington, D.C. 20415-3430. The OMB number, 3206-0190, is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.
Instruction Page 3, RI 92-19
Revised May 2012
Form Approved:
Application for Deferred or Postponed Retirement
OMB No. 3206-0190
Federal Employees Retirement System
Federal Employees
Retirement System
Section A - Identifying Information
3.Date of birth (mm/dd/yyyy)
1.Name (Last, first, middle)
2.List all other names used
5b.Best time to reach you
4.
Address (Number, street, city, state, ZIP Code) 5a.Daytime telephone number
6.Email address
7.Social Security Number
8.
Are you a citizen of the United States of America?
Yes No
Section B - Federal Civilian Service
1.
Date on which you separated from Federal service (mm/dd/yyyy)
2.
What agency did you separate from? (Give agency, group or office)
3.
List below all Federal service you have performed.
Location (City and state) Department or Agency, including Bureau or Division
Section C - Military Service
To (mm/dd/yyyy)From (mm/dd/yyyy)
Dates of Service
1.Have you performed active, honorable service in the Armed Forces or other uniformed services of the United States? (See instructions for definition.)
Yes, go to item 2.
No, go to Section D.
2.
If you have military service performed after 1956, did you pay a deposit to your former employing agency?
Not applicable, go to item 3. Yes, go to item 2a. No, go to item 3.
2a. When did you pay your deposit for post-56 military service? (mm/dd/yyyy)
2b.To which agency did you make the payment? (Give agency, bureau or division and
location)
3. If you have performed active, honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definition), complete 3a-d
below and attach a copy of your discharge certificate or other certificate of active military service (if available).
3a. Branch of Service 3b. Serial Number
From (mm/dd/yyyy)
3d. Last Grade or Rank
To (mm/dd/yyyy)
3c. Dates of Active Duty
Yes, complete items 4a-4c.
No, go to Section D.
Yes, if available, attach a copy of notice of award.
No
Yes, if available, please attach a copy of notice of award.
No
No
Yes, see instructions for information about how to request a waiver.
Yes, a copy of my waiver is attached.
4.
Are you receiving or have you ever applied for military retired or retainer
pay (including disability retired pay)?
4a.
Was your military retired or retainer pay awarded for disability incurred in combat or
caused by an instrumentality of war and incurred in the line of duty during a period
of war?
4b. Was your military retired or retainer pay awarded for reserve service
under Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10)?
4c. Are you waiving your military retired pay in order to receive credit for FERS?
Office of Personnel Management
CSRS/FERS Handbook
RI 92-19
Previous edition is not usable
Continued on reverse
Revised May 2012
Section D - Other Claim Information
1.Have you previously filed any application under the Federal Employees Retirement System or Civil Service Retirement System (for refund, retirement, deposit,
redeposit, etc.)?
Yes (Complete items 1a and 1b)
No
Retirement
Refund
Deposit/redeposit
Refund of excess deductions
1a. Type of application
1b. Claim number(s)
2. Have you ever been employed under another retirement system for Federal or District of Columbia employees?
Refunded
NoYes
2e. Were retirement
deductions withheld?
2d. Title of Position
Yes (Complete below)
From (mm/dd/yyyy)
2c. Location of
Employment
No
To (mm/dd/yyyy)
2b. Dates of Service
2a. Name of other
Retirement System
3.Have you ever received workers' compensation from the Department of Labor because of a job-related illness or injury?
Yes, complete 3a thru 3c. No
From (mm/dd/yyyy)
Section E - Marital Information
Scheduled Award Other
To (mm/dd/yyyy)3a. Compensation Claim Number 3b. Description of benefit 3c. Date benefits
received
Total/partial disability
1.Are you married? If separated from your spouse, but the marriage has not ended by divorce or annulment, answer "Yes."
Yes (Complete items 1a thru 1f.)
No
1a. Spouse's name (Last, first, middle) 1b. Spouse's date of birth (mm/dd/yyyy) 1c. Spouse's Social Security Number
1d.Place of marriage (City, state) 1e. Date of marriage (mm/dd/yyyy) 1f.Marriage
Clergyman or Justice of the Peace
performed by
Other (Explain)
2.Do you have a living former spouse(s) to whom a court order gives a survivor annuity or a portion of your retirement benefits based on
your Federal employment?
No
Yes
Statement regarding
Former Spouses
Section F - Annuity Election
Read the attached instructions before making this election.
Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested. Consider your election carefully. No change will
be permitted after your annuity is granted except as explained in the pamphlet Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement System,
RI 92-19A. If you are currently married and you do not elect maximum survivor benefits the law requires that your spouse consent to your election; therefore, you must
complete Schedule A and attach it to this application.
Your election to provide a survivor annuity for a current spouse terminates upon the death of that spouse or if the marriage ends due to divorce or annulment. You are required to
make a new election (reelect) within 2 years of the terminating event if you wish to reelect a survivor annuity for a former spouse or within 2 years of a post-retirement marriage to
elect a survivor annuity for a spouse acquired after retirement. Continuing a survivor reduction, by itself, is not effective to reelect a survivor annuity for a spouse married after
retirement or for a former spouse.
If you want to elect a partial survivor annuity for your current spouse and a survivor benefit for a former spouse, you should complete options 2 and 5 below. The total of the
survivor annuities elected cannot exceed 50 percent. An election of an insurable interest survivor in option 4, is not included when determining the 50 percent maximum.
1. I choose a reduced annuity with maximum survivor annuity for my spouse named in Section E.
Initials
If you are married at retirement you will automatically receive this type of annuity unless your spouse consents to your election not to
provide maximum survivor benefits. If you receive this annuity, your annuity will be reduced by 10%. The survivor's annuity upon your
death will be 50% of your unreduced annuity.
2. I choose a reduced annuity with a partial survivor annuity for my spouse named in Section E.
Initials
If you choose this option, your annuity will be reduced by 5%. Upon your death, your spouse's annuity will be 25% of your unreduced
annuity. You must have your spouse's consent to choose this option. Attach Schedule A showing your spouse's consent.
3.I choose an annuity payable only during my lifetime.
No current spouse survivor annuity will be paid to your spouse after your death if he or she consents to this election. If you are married
at retirement, you cannot choose this type of annuity without your spouse's consent. You should initial this box if you are electing an
insurable interest benefit (Box 4) for your current spouse. Attach Schedule A showing your spouse's consent. If you are eligible to
Initials
continue your health benefits coverage into retirement, your spouse's health benefits coverage will terminate upon your death. In
addition, your spouse will not be eligible to enroll in the Federal Long Term Care Insurance program, if he/she is not enrolled at the
time of your death.
4. I choose a reduced annuity with survivor annuity for the person named below who has an insurable interest in me.
Initials
You must be healthy and willing to provide medical evidence if you choose this type of annuity.
Name of person with insurable interest Relationship to you
Date of birth (mm/dd/yyyy) Social Security Number
Office of Personnel Management
Reverse of Page 1
CSRS/FERS Handbook
RI 92-19
Previous edition is not usable
Revised May2012
5. I choose a reduced annuity with survivor annuity for my former spouse(s) as follows:
You must attach:
1. Certified copies of divorce decrees for all former spouses for whom you elect to provide survivor annuity.
2.If you are married, attach a completed Schedule A (Spouse's Consent to Survivor Election). You cannot
choose this option and provide a maximum survivor annuity for your spouse (Box 1).
Your election to provide a survivor annuity for a former spouse terminates upon the death of that spouse or the remarriage of your
former spouse before age 55 (unless your marriage to the former spouse lasted for 30 years or longer).
This election when combined with an election in Box 2 cannot exceed 50% of your unreduced annuity.
Persons who completed Box 1 may not complete Box 5.
Initials
Name and address of former spouse Date of marriage (mm/dd/yyyy) Date of divorce (mm/dd/yyyy) Survivor annuity equal to this
percent of my annuity
Date of birth (mm/dd/yyyy) Social Security Number
%
Name and address of former spouse Date of marriage (mm/dd/yyyy) Date of divorce (mm/dd/yyyy) Survivor annuity equal to this
percent of my annuity
Date of birth (mm/dd/yyyy)
Social Security Number
%
Total (Must equal either 25% or 50%)
%
Disabled
Date of Birth
(mm/dd/yyyy)
Dependent Child's Name
(First, middle, last)
Disabled
Date of Birth
(mm/dd/yyyy)
Dependent Child's Name
(First, middle, last)
Section H - Payment Instructions
Section G - Information About Your Unmarried Dependent Children
1.Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department of
Treasury. See page 2 of the instructions for this application and RI 92-19A (Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement
System) for additional information. This does not apply to you if your permanent payment address is outside of the United States in a country not accessible via direct
deposit.
Please select one of the following:
Please send my annuity payments directly to my checking or savings account. (Go to item 2)
Please send my annuity payments to my Direct Express debit card. (Go to Section I)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to Section I)
2. Please provide information about your financial institution below.
2a.Financial institution routing number 2c.Name and address of financial institution 2d.Telephone number of
your financial institution
(including area code)
2b.Account number
Checking
Savings
Section I - Applicant's Certification
Warning
I hereby certify that all statements made in this application are true to the best of my knowledge and that no evidence
Any intentionally false statement in this application
necessary to the settlement of this claim is withheld. I have read and understand all the information provided in the
or willfully misleading statement or response you
instructions to this application.
provide in this application is a violation of the law
Signature (Do not print)
Date (mm/dd/yyyy)
punishable by a fine of not more than $10,000 or
imprisonment of not more than 5 years or both (18
U.S.C. 1001).
Office of Personnel Management
Page 2
CSRS/FERS Handbook
RI 92-19
Previous edition is not usable
Revised May 2012
0
Schedule A - Spouse's Consent to Survivor Election
Instructions - Complete this schedule if you are married and do not elect a reduced annuity to provide a full current spouse survivor
annuity. Complete Part 1. Have your spouse complete Part 2. Part 2 must be completed in the presence of a Notary Public or other
person authorized to administer oaths. The Notary Public must complete Part 3.
Part 1 - To Be Completed By the Applicant
Name (Last, first, middle) Social Security Number Date of birth (mm/dd/yyyy)
I have elected (Mark all boxes which describe the survivor elections you have made.)
A.No regular or insurable interest survivor annuity for my current spouse. I understand that:
No survivor annuity will be paid to my spouse after my death.
If I am eligible to continue my health benefits coverage into retirement, his/her health benefits coverage will terminate upon my death, and
He/she will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) after my death.
B.
A partial survivor annuity for my current spouse equal to 25% of my annuity.
C.
An insurable interest survivor annuity for my current spouse, but no regular survivor annuity for my current spouse.
D.
A maximum survivor annuity for my former spouse ________________________________________________.
(I have completed Section F, Box 4, on my RI 92-19, naming my current spouse.)
E.
A partial survivor annuity for my former spouse ___________________________________________________ equal to 25% of my annuity.
(name of former spouse)
F.
A partial survivor annuity for my former spouse ___________________________________________________ equal to 25% of my annuity.
(name of former spouse)
(name of former spouse)
I freely consent to the survivor annuity election described in Part 1. I understand that my consent is final (not revocable).
Part 2 - To Be Completed By Current Spouse of Applicant
Name (Type or print) Signature (Do not print) Date (mm/dd/yyyy)
Part 3 - To Be Completed By a Notary Public or
Other Person Authorized to Administer Oaths
I certify that the person named in Part 2 presented identification (or was known to me), gave consent, signed or marked this form, and acknowledges that the consent was freely
given in my presence on this the __________________________ day of ______________________________________, ____________
(Month) (Year)
at ____________________________________________________________________________________________ .
(City, state)
Seal
Signature (Do not print)
Expiration date of Commission, if Notary Public (mm/dd/yyyy)
General Information
Public Law 99-335 requires that a person who is married at the time his or her retirement annuity begins must elect to provide a full survivor annuity for a current spouse, unless
the current spouse consents to some other election by signing this form.
A court order which requires an annuitant to provide a survivor annuity for a former spouse is not an election and spousal consent is not required. In other words, such a court order
does not require a current spouse to waive the right to a survivor annuity. The retiring employee can still elect to provide a survivor annuity for the current spouse even though the
Office of Personnel Management (OPM) must honor the terms of the court order before it can honor the election for the current spouse. The current spouse may, therefore, receive
a smaller annuity than elected, or none at all, unless the former spouse loses eligibility for the court-ordered survivor annuity (through the terms of the court order, remarriage
before age 55, or death).
Privacy Act and Public Burden Statement
Public Law 99-335, which established the spousal consent requirement for FERS, authorizes solicitation of this information. The data furnished will be used to determine the
type of annuity awarded. 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 to determine and issue benefits under those programs. It may also be shared and verified, as
noted above, with law enforcement agencies when they are investigating a violation of civil or criminal law. Executive Order 9397 (November 22, 1943), authorizes the use of
the Social Security Number. Failure to furnish the requested data will delay or prevent action on the retirement application.
We estimate that this form takes an average of 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 (3206-0190), Washington, D.C. 20415-3430. The OMB number, 3206-0190, is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is displayed.
Office of Personnel Management
CSRS/FERS Handbook
RI 92-19
Previous edition is not usable
Revised May 2012
Schedule B - For Applicants with Immediate MRA+10 Eligibility
(who may choose to postpone)
To be completed only by applicants who were eligible for an immediate MRA+10 annuity based on having reached the Minimum
Retirement Age and having at least 10 years of creditable service at separation. Read instructions carefully to determine if you
should complete this schedule.
Read the instructions carefully and
elect when you want your benefits to begin.
I want my benefit to begin accruing (mm/dd/yyyy)
Name (Last, first, middle)
Date of birth (mm/dd/yyyy) Social Security Number
Part 1 - Identifying Information
Part 2 - Commencing Date
Part 3 - Health Benefits Coverage
1.When you separated from service, were you enrolled (or covered as a family member) in the Federal Employees Health Benefits Program?
Yes, complete items 1a-1c.
No, go to Part 4.
Plan NameEnrollment Code
1a.
What plan were you enrolled in when you separated (if known)?
1b.
1c.
Yes, attach copy.
No
Part 4 - Life Insurance Coverages
Yes
No
Do you want information on reenrolling with the
Federal Employees Health Benefits Program?
Do you have a copy of your SF 2810
terminating your enrollment?
1.
When you separated from service, were you enrolled in the Federal Employees' Group Life Insurance Program?
Yes (Also complete items 1a-1d).
No, go to Part 5.
Basic
Option C -- Family __________# of multiples (if known)
1d.
1a.
Option A -- Standard
Option B -- Additional _________# of multiples (if known)
1b.
1c.
No
No
No
Yes
Yes, attach copy. Yes
What coverage(s) did you have when you separated? Do you want information on starting
your coverage(s) again?
Do you have a copy of your SF 2821 terminating your coverage(s)? Did you convert your coverage(s) to a private plan?
Part 5 - Federal Dental and Vision Program Coverage
1.
When you separated from service, were you enrolled in the Federal Dental and Vision Program (FEDVIP)?
Yes (Also complete items 1a-1b). No, go to Part 6.
Plan Name
1a.
What plan were you enrolled in when you separated (if known)?
1b.
Do you want information on reenrolling with the Federal Dental and Vision Program?
Yes
No
Part 6 - Long Term Care Insurance Coverage
1. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?
Yes. Your coverage will continue. If you want your premium paymentsNo. If you are not currently enrolled in the Federal Long Term Care
deducted from your annuity, call the FLTCIP administrator, Long Term CareInsurance Program, you, your spouse, and your adult children may apply for
Partners, at 1-800-582-3337.coverage provided you are eligible for a deferred or postponed annuity. You
may request an application by contacting Long Term Care Partners, at
1-800-582-3337.
Signature Date (mm/dd/yyyy)
Part 7 - Applicant's Signature
Office of Personnel Management CSRS/FERS Handbook RI 92-19
Previous edition is not usable Revised May 2012
Schedule C - For Applicants with Deferred MRA+10 Eligibility
(who may choose to postpone)
To be completed only by applicants eligible for a deferred (non-immediate) annuity based on a separation from FERS covered
Federal service before attaining the Minimum Retirement Age and after performing at least 10 years of creditable service. Read the
instructions carefully to determine if you should complete this Schedule.
Read the instructions carefully and
elect when you want your benefits to begin.
Part 1 - Identifying Information
Name (Last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
Part 2 - Commencing Date
I want my benefit to begin accruing (mm/dd/yyyy)
Part 3 - Long Term Care Insurance Coverage
1. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?
Yes. Your coverage will continue. If you want your premium payments
No. If you are not currently enrolled in the Federal Long Term Care
deducted from your annuity, call the FLTCIP administrator, Long Term Care
Insurance Program, you, your spouse, and your adult children may apply for
Partners, at 1-800-582-3337.
coverage provided you are eligible for a deferred or postponed annuity. You
may request an application by contacting Long Term Care Partners, at
1-800-582-3337.
Signature
Part 4 - Applicant's Signature
Date (mm/dd/yyyy)
Office of Personnel Management CSRS/FERS Handbook RI 92-19
Previous edition is not usable Revised May 2012
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