Fillable Printable SF 2812A-1
Fillable Printable SF 2812A-1
SF 2812A-1
Report of Withholdings and Contributions for Health Benefits By Enrollment Code
Standard Form 2812-A
Revised October 2014Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices This form may be locally reproduced
Department or establishment Payroll Office number Report number
Bureau, division or office Pay period from Pay period to
Address (including ZIP Code ) Date payroll paid
( )
Agency telephone number
Enrollment
Code No.
Total Withholdings
& Contributions
Number
enrolled*
Enrollment
Code No.
Total Withholdings
& Contributions
Number
enrolled*
Enrollment
Code No.
Total Withholdings
& Contributions
Number
enrolled*
*Number of enrollees is required on report, for
the last payroll periods paid during the 1st through the 15th of March and September.
