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Fillable Printable Form RI25-41

Fillable Printable Form RI25-41

Form RI25-41

Form RI25-41

Form Approved
OMB No. 3206-0099
United States
Office of Personnel Management
Retirement Operations
Washington, DC 20415
Initial Certification of
Full-Time School Attendance
Reference
Date (mm/dd/yyyy)
Claim number(suffix)
CSF
Name of deceased employee
Name of child
Date of death (mm/dd/yyyy)On roll?
YesNo
The Application for Death Benefits shows that the child named
above, a survivor of a Federal employee or annuitant, is (or soon
will be) age 18. After reaching age 18, a child is eligible for a
survivor annuity only if unmarried and (1) a full-time student in an
accredited school or (2) incapacitated for self-support because
of a physical or mental disability that began before age 18.
If a child is unmarried and incapacitated for self-support because
of a mental or physical disability, do not fill in the other side of
this form. Instead, return the form to us with a doctor's certificate
describing the nature and extent of the child's disability. After we
review the documentation of the disability, we will write to you
about the child's eligibility for benefits.
If the child is unmarried and a full-time student, you should
complete Part A on the other side of this form; a school official
(the principal, administrator, registrar, etc.) should complete Part
B, and you should return the completed form to us promptly. If
the child's school year was not in session on the date of death
(shown above), have the school official complete Part B for the
last school year attended.
Send the completed form to:
U.S. Office of Personnel Management
Retirement Operations
1900 E Street, NW
Washington, DC 20415-3563
Privacy Act Statement
The Office of Personnel Management (OPM) administers the Civil Service Retirement System (Chapter 83, title 5, U.S. Code) and the Federal Employees
Retirement System (Chapter 84, title 5, U.S. Code). The information requested on the enclosed form is needed to document a retirement benefit or claim.
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, to obtain information necessary
for determination or continuation of benefits from OPM, 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. Executive Order 9397 (November 22, 1943)
authorizes the use of the Social Security Number. Providing the information is voluntary; however, failure to supply all the requested information may delay
or prevent action on the benefit or claim. Intentionally false statements and/or suspected illegal activities are reportable by us to the appropriate law
enforcement agencies.
Public Burden Statement
We estimate this form takes an average 90 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, Retirement
Services Publications Team (3206-0099), Washington, DC20415-3430. TheOMBNumber
3206-0099 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
(THIS SPACE IS FOR THE USE OF THE OFFICE OF PERSONNEL MANAGEMENT ONLY.)
Remarks:Call up (M-Card) processed
ApprovedNot Approved Because
Less than full-time school attendance
Not in school
Over 5-month break in attendance
Married
Non-recognized school
Other (specify)
Benefits specialist
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)Inspector
RI 25-41
Revised
February2013
Previous editions are usable.
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Part A -To be completed by the payee (the person who expects to receive benefits for the student).
Read the reverse side of this form before answering the questions below; give full information; typewrite or print in ink.
1. Student's name (first, middle, last) 2. Student's date of birth (mm/dd/yyyy) 3. Student's Social Security Number
4. Is the student married?
Yes
No
If "Yes," show the date at right, sign item 7 of this part, and
return this form. (It is not necessary to complete the rest of the
form.)
Date of marriage (mm/dd/yyyy)
Current
Status
5. Is the student enrolled in
school on a full-time basis
at the present time?
Yes
No
If "No," show the date the student last attended
school on a full-time basis.
Last attended school (mm/dd/yyyy)
Future
Plans
6. After the end of the school
year, does the student
intend to continue as a
full-time student with less
than a 5-month break
between school years?
Yes
No
Undecided
If "Yes," give the details in items 6a and 6b.
If "No" or "Undecided," go to item 7.
}
6a. Enter the date (or approximate
date) the next school year or
term begins after current
enrollment (month, day, year).
6b. Complete name and mailing address (including ZIP code) of the educational institution the
student will attend next year.
Payee
Signs
Here
7. 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 further agree to return all overpayments of
student benefits, including overpayments that may be erroneously made after I notify OPM of any terminating event. I authorize the
appropriate school official to verify the student's school attendance status to OPM in the manner requested by that agency.
Signature of payee
Email address Daytime telephone number
( )
Date (mm/dd/yyyy)
Part B -To be completed by an official of the educational institution for the school year to .
(month, year) (month, year)
6. Show the total school hours per week:
4. Check the type of educational institution:
College or
university
Vocational institute
Junior college/
community college
1. Is/was the student enrolled in and attending a
full-time course of resident study or training
(not correspondence) for the period requested?
3. Official ending date of the
school year (mm/dd/yyyy)
2. Actual date the student started school for the
school year indicated above (mm/dd/yyyy)
Yes No
High school
Trade school
Technical institute
Other (specify)
5. Show the complete name and mailing address
(including ZIP code) of the educational institution.
a. If college or equivalent, show credit hours
b. If high school or equivalent, show actual clock hours
c. If in a work-study program sponsored by the school,
show hours at work
hours at school
Complete items 7 and 8 below if your institution is not a state college, state university, or public high school.
7. Show the complete name and address (including ZIP code) of the
organization which accredits, licenses, or otherwise recognizes the school.
8. If the educational institution is licensed, show:
a. Current license number: b. Expiration date of current license
(mm/dd/yyyy)
School
Official
Signs
Here
I certify that the information given in regard to requested school enrollment of the
above-named student is true and correct to the best of my knowledge and belief.
Signature of principal, administrator, registrar, etc. Telephone number
Warning: Any intentionally false statement, willful
concealment of material fact, or use of a writing or
document knowing the same to contain a false,
fictitious, or fraudulent statement or entry, is a violation
of the law 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)
Title Date (mm/dd/yyyy)
( )
Reverse of RI 25-41
Revised February 2013
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