Fillable Printable SF 3102
Fillable Printable SF 3102
SF 3102
Designation of Beneficiary
Form Approved
OMB No. 3206-0173
Federal Employees Retirement System
Important:
Federal Employees
Read all instructions before
Retirement System
filling in this form
A. Identification
Name (Last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
Place an "X" in the
appropriate box:
¯
An employee Retired or an
applicant for
retirement
Former employee eligible
for retirement in the
future
If you are retired give your claim number
Bureau Division Location (City, state and ZIP code)
Department or agency in which presently employed (or former department or agency):
Department or agency
I, the individual identified above, designate the beneficiary or beneficiaries
named below to receive any lump-sum benefit which may become payable
under the Federal Employees Retirement System (FERS) after my death,
including lump-sum death benefits which may become payable based on
amounts contributed to the Civil Service Retirement System (CSRS) before
I became covered by FERS. I understand that this designation of beneficiary
cancels any previous FERS or CSRS designation of beneficiary, and that it
remains in effect until I cancel it in writing or I receive payment of my
FERS retirement contributions.
I direct, unless otherwise indicated below, that if more than one
beneficiary is named, the share of any beneficiary who may predecease
me or who may be disqualified for any other reason, shall be distributed
equally among the stated beneficiaries, or entirely to the survivor. If none
of the beneficiaries are alive and eligible to receive payment when a
lump-sum payment becomes payable, this designation is void, and
payment will be made according to the order of precedence set by law.
Date of designation (mm/dd/yyyy)
Address (Including ZIP code) of
each beneficiary
B. Information Concerning The Beneficiaries (See Examples of Designations):
First name, middle initial, and last
name of each beneficiary
Relationship
to you
Share to be paid to
each beneficiary
Your signature
Total = 100%
C. Witnesses (A witness is not eligible to receive payment as a beneficiary):
We, the undersigned, certify that this statement was signed in our presence.
Signature of witness
Address (including ZIP code)
Signature of witness Address (including ZIP code)
Receiving agency certification
I have reviewed this designation and certify that the designated shares total 100% and that no witnesses are designated as beneficiaries.
Date received by agency (mm/dd/yyyy) Signature Date (mm/dd/yyyy)
We will pay to the person you designate, even if that person's name or relationship to you changes after you file this designation. For example, suppose you designate your spouse
and then you two divorce and you marry someone else. We will pay any lump sum to your former spouse unless you submit another designation to cancel prior designations or to
designate who we are to pay.
We will write to the address you provide here to contact the person you designate. However, that person is obligated to get in touch with us after your death to ask us to make
payment.
Type or print your return address so that we can return a copy to you.
See Back of Employee Copy For Instructions
On Where To File This Form.
(Retain until employee leaves Federal
service and then send to the Office of Personnel
Management [OPM].)
U.S. Office of Personnel Management
5 CFR 843.205
Previous editions are usable.
Standard Form 3102
Revised February 2012
Part 1 - Original Copy
PRINT
SAVE
CLEAR
Important - The filing of this form will completely cancel any Designation of Beneficiary under the Federal Employees Retirement System or under the Civil
Service Retirement System you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries of any lump sum
payable at your death.
Examples of Designations
1. HOW TO DESIGNATE ONE BENEFICIARY Do not write names as M.E. Brown or as Mrs. John H. Brown. If you want to designate your estate as
beneficiary, enter "My estate" in the beneficiary column.
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code)
of each beneficiary
Relationship
to you
Share to be paid to
each beneficiary
Mary E. Brown
214 Central Avenue
Muncie, IN 47303
Niece 100%
2. HOW TO DESIGNATE MORE THAN ONE BENEFICIARY Be sure that the shares to be paid to the several beneficiaries add up to 100 percent.
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code)
of each beneficiary
Relationship
to you
Share to be paid to
each beneficiary
Alice M. Long
509 Canal Street
Red Bank, NJ 07701
Aunt 25%
Joseph P. Brady
360 Williams Street
Red Bank, NJ 07701
Domestic Partner 25%
Catherine L. Rowe
792 Broadway
Whiting, IN 46394
Mother 50%
3. HOW TO DESIGNATE A CONTINGENT BENEFICIARY
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code)
of each beneficiary
Relationship
to you
Share to be paid to
each beneficiary
John M. Parrish, if living
810 West 180th Street
New York, NY 10033
Father 100%
Otherwise to: Susan A. Parrish
810 West 180th Street
New York, NY 10033
Sister 100%
4. HOW TO DESIGNATE AN INTER VIVOS TRUST (A trust that you set up during your lifetime)
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code)
of each beneficiary
Relationship
to you
Share to be paid to
each beneficiary
Trustee(s) or Successor
Trustee(s) as provided in the
John Q. Public Trust
Agreement dated 12/18/1999,
if valid. Otherwise to:
Trustee 100%
Mary E. Brown
214 Central Avenue
Muncie, IN 47303
Niece 100%
5. HOW TO DESIGNATE A TESTAMENTARY TRUST (A trust that is set up when you die, according to terms in your will)
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code)
of each beneficiary
Relationship
to you
Share to be paid to
each beneficiary
Trustee(s) or Successor
Trustee(s) as provided in my
Last Will and Testament, if
valid. Otherwise to:
Trustee 100%
Maria Sufuentes
5909 Pacific Avenue, NW
Washington, DC 20019
Niece 100%
6. HOW TO CANCEL A DESIGNATION OF BENEFICIARY AND EFFECT PAYMENT UNDER ORDER OF PRECEDENCE (See back of employee copy)
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code)
of each beneficiary
Relationship
to you
Share to be paid to
each beneficiary
Cancel prior designations
Standard Form 3102 (Reverse of Part 1)
Revised February 2012
Do not fill out this form until you have read the information and instructions below
Instructions
This Designation of Beneficiary Form is used to designate who is to receive a lump-sum payment which may become payable under the Federal Employees
Retirement System (FERS). It does not affect the right of any person who is eligible for survivor annuity benefits. This form may not be used and will not be
effective in any way to elect, or demonstrate the intent to elect, a survivor annuity for a spouse, former spouse, or an individual who has an insurable interest in
an employee. Do not confuse this form with designation forms used for other types of benefits: Standard Form 2808, Designation of Beneficiary - Civil Service
Retirement System; Standard Form 2823, Designation of Beneficiary - Federal Employees' Group Life Insurance Program; TSP-3, Thrift Savings Plan Designation
of Beneficiary; or Standard Form 1152, Designation of Beneficiary - Unpaid Compensation of Deceased Civilian Employee.
This form is only for employees and retirees under FERS. Employees and retirees under the Civil Service Retirement System (CSRS) must use Standard Form
2808, Designation of Beneficiary - Civil Service Retirement System. If you transferred from CSRS to FERS and previously filed an SF 2808, Designation of
Beneficiary - Civil Service Retirement System, your SF 2808 is invalid. You must file a new designation using this form.
Important - The filing of this form will completely cancel any Designation of Beneficiary under FERS or CSRS (SF 3102 or SF 2808) you may have previously
filed. Be sure to name in this form all persons you wish to designate as beneficiaries for FERS lump-sum death benefits, including lump sum payment of
amounts you may have contributed to CSRS before becoming covered by FERS.
Order of Precedence
You do not need to make a designation if you are satisfied with the order of
precedence that the law provides. That order of precedence follows:
1.
To your widow or widower.
2.
If your widow(er) is deceased, to your child or children, with the share of
any deceased child distributed among the descendants of that child.
3.
If none of the above, to your parents in equal shares or the entire
amount to the surviving parent.
4.
If none of the above, to the executor or administrator of your estate.
5.
If none of the above, to your other next of kin under the laws of the State
in which you live at the time of your death.
Payment of a lump sum will be made to the first person or persons listed
above who are alive on the day you die.
Designating a Beneficiary
1.
You can designate any person, firm, corporation, trust, or legal entity as
your beneficiary.
If you want to designate a trust, see examples 4 and 5 on the back of
Part 1. Those examples name a contingent beneficiary in case the trust
is not valid. You don't have to name a contingent beneficiary unless you
want to. If the trust is not valid, and you do not name a contingent
beneficiary, OPM will pay according to the order listed under "Order of
Precedence" above.
2.
You can change your beneficiary at any time, without the knowledge or
consent of a previous beneficiary, and this right cannot be waived or
restricted.
3.
A designation of beneficiary must be in writing, signed, and witnessed.
If you are an employee, the designation must be received in your
employing office prior to your death. If you are a separated employee,
a retiree or a person receiving recurring payments from the Office of
Workers' Compensation Programs (OWCP), the designation must be
received by the Office of Personnel Management (OPM) prior to your
death.
4.
A witness to a designation of beneficiary is ineligible to receive payment
as a beneficiary.
5.
The person(s) named will be considered a beneficiary (beneficiaries) for
both CSRS and FERS lump-sum benefits.
6.
You cannot change or cancel a designation of beneficiary in a last will
or testament unless it is signed, witnessed, and filed as described in
paragraph 3.
7.
A designation of beneficiary remains in effect until (1) you cancel it by
filing a new designation, or (2) you receive a refund of your retirement
deductions before retirement. To inform us if the name or address of a
beneficiary changes, file a new designation of beneficiary. It may be
important to file a new designation if your family situation changes.
Completing the Designation Form
1.
The examples printed on the back of the first page of this form may be
helpful to you in naming a beneficiary or canceling a prior designation of
beneficiary.
2.
If you designate more than one beneficiary, be sure that the shares to
be paid to them add up to 100 percent. Do not use dollar amounts to
indicate the shares.
3.
If you wish to designate more than four persons in Part B, use a blank
sheet of paper which you will attach to the form. Print your name and
date of birth at the top of the attachment and provide the information
required in Part B for each beneficiary. Your signatures on the form and
on the attachment must be witnessed by the same two people. The
witnesses must sign both the form and the attachment.
4.
Complete the form in duplicate. Type or print all entries except
signatures. Do not use pencil.
5.
Do not erase or alter entries.
Where to Submit the Completed Form
For employees: File this form with your employing agency, even if you are
retiring.
For separated employees, retirees and individuals receiving recurring
benefits from the Office of Workers' Compensation Programs (OWCP):
If you have left Federal employment, if you are receiving recurring benefits
from the Office of Workers' Compensation Programs, or if you have retired,
file this form with the Office of Personnel Management, Retirement
Operations Center, Federal Employees Retirement System, P.O. Box 45,
Boyers, PA 16017-0045.
Your designation will not be effective until the date it is received by your
employing agency (or OPM if you are not employed).
The employee copy of this form will be noted and returned to you as
evidence that the original has been received and filed. Please keep the
duplicate in a safe place along with your other important papers.
For the employing agency: File the Official Personnel Folder (OPF) copy
on the right side of the OPF. If the employee leaves Federal service, send
all FERS designations in the OPF to OPM.
Privacy Act and Public Burden Statements
Solicitation of this information is authorized by the Civil Service Retirement law
(Chapter 83, title 5, U.S. Code) and the Federal Employees Retirement law (Chapter
84, title 5, U.S. Code). The information you furnish will be used to determine who will
receive a lump sum benefit in the event of your death. 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 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.
Executive Order 9397 (November 22, 1943), authorizes the use of the Social Security
Number. Failure to furnish the requested data may delay or make it impossible for us
to determine how to make payment in the event of your death.
We estimate providing this information takes an average of 15 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 SF 3102, including suggestions for reducing completion time, to the
U.S. Office of Personnel Management (OPM), Retirement Services Publications Team
(3206-0173), Washington, D.C. 20415-3430. The OMB number, 3206-0173 is currently
valid. OPM may not collect this information, and you are not required to respond,
unless this number is displayed.
Standard Form 3102 (Reverse of Part 2)
Revised February 2012
