Fillable Printable OPM Form 1522

OPM Form 1522

United States

Office of Personnel Management

Request for Offset for Health Benefits Premiums

From Monies Payable Under the Civil Service Retirement System (CSRS)

or the Federal Employees Retirement System (FERS)

(In Lieu of Standard Form 2805)

Office of Personnel Management

Retirement Operations Center

Boyers, PA 16017

The former employee named below is indebted to the United States (under § 890.502(b) of title 5, Code

of Federal Regulations) for health benefits premiums. To liquidate this indebtedness, we request that

you set off the gross amount of the debt as shown below, against the former employee's account in the

Civil Service Retirement and Disability Fund. The former employee's retirement record (Standard Form

2806 or Standard Form 3100) is is not attached.

Name of office designated by the employing agency to receive evidence of the liquidation of the debt.

Street address

City, state, and ZIP code

Retirement system

FERS CSRS

Social Security Number

From To

Date

(typed or printed) Telephone number(typed or printed)

Payroll office number

Each period of non-pay status

for which offset is required

Name of former employee

Date of birth Date of termination of service

Amount of debt for each period Total amount of debt

Location of employment (city, state)

Appropriation or fund (title and symbol number) Disbursing office (name and symbol number)

I certify that this debt is properly due the United States, and that before making this request, we notified

this individual that OPM will make the collection from any CSRS or FERS benefits payable. A copy of

the former employee's signed consent is attached.

Signature of certifying official

Name of certifying official (including area code) Title of certifying official

OPM 1522

Revised June 2006

Previous edition is not usable.

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