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Fillable Printable SF 3107

Fillable Printable SF 3107

SF 3107

SF 3107

Application for Immediate Retirement
Federal Employees
Retirement System
Federal Employees Retirement System
This application is for you if you are a Federal employee covered by the Federal Employees Retirement System (FERS) and you wish
to apply for retirement with an immediate annuity. You should use this application if you want to apply for an annuity which will
begin within 30 days of your separation from Federal service.
Do not use this application to apply for a deferred annuity. A deferred annuity begins more than 30 days after the date of final
separation. If you want to apply for a deferred annuity, call the Office of Personnel Management (OPM) on 1-888-767-6738
(TTY: 1-855-887-4957) to request an RI 92-19, FERS Application for Deferred or Postponed Retirement. If you prefer, you can
write to us at Office of Personnel Management, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045, or
email us at retire@opm.gov. You can also find this form on our website at www.opm.gov/forms/Retirement-and-Insurance-Forms.
You should have received an informational pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees
Retirement System, with this application. If you did not receive the pamphlet you should get a copy from your employing agency or
from our website at
www.opm.gov/retirement-services/publications-forms/pamphlets/#url=FERS.
Retirement benefits and retirement processing are complicated. Read the information in the pamphlet carefully. When you decide to
retire, give your agency advance notice so it can be sure your records are complete and it can carry out its responsibilities in
processing the paperwork associated with your retirement.
Give your completed application to the personnel office of your employing agency. They will forward your application to your
agency payroll office and then to the Office of Personnel Management for processing. If you have any questions, ask your employing
office for assistance.
You must apply separately for any benefits payable from the Thrift Savings Plan and the Social Security Administration.
If your address changes after your application has been forwarded to the Office of Personnel Management, call us on 1-888-767-6738
(TTY: 1-855-887-4957). If you prefer, you can write to us at the address above. If you have received your claim number, please refer
to it. If you have not received your claim number we'll need your name, date of birth and social security number.
Instructions for Completing Application
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 unsure of information (for
example, if you do not know an exact date), answer to the best
of your ability, followed by a question mark (?).
The following additional information should help you to answer
those questions on the application which are not entirely
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 records
maintained under these names.
Item 3:Enter the address to which correspondence should be
mailed. Do not enter the bank address where your
payments will be deposited here; see Section H of the
application form for payment information.
Item 4:Give a telephone number where you can be reached
after you retire and the best time to reach you during
business hours.
Section B - Federal Service
Item 2:Enter the date of final separation for retirement. (Leave
blank if applying for disability retirement and not
separated.) Please note that if you are currently serving
in more than one appointive or elective position in the
Federal Government, you must separate from all such
positions before you can qualify for an immediate
retirement.
Item 4:Indicate whether or not 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:
a.Army, Navy, Marine Corps, Air Force or Coast
Guard of United States;
b.Regular Corps or Reserved Corps of the Public
Health Service after June 30, 1960;
c.Commissioned Officer of the National Oceanic
and Atmospheric Administration after June 30,
1961 or a predecessor entity in function;
d.Cadet at the U.S. Military Academy, U.S. Air
Force Academy, U.S. Coast Guard Academy, or
midshipman at the U.S. Naval Academy.
e.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.
CSRS/FERS Handbook for Personnel and Payroll Offices
Standard Form 3107
3107-10
8
Previous editions are not usable.
Revised May 2014
2
Standard Form 3107
Revised May 2014
If you have performed such service, complete and
attach Schedule A, furnishing the requested information
for each period of active duty.
To receive FERS credit for military service performed
on or after January 1, 1957, you must pay a deposit.
The amount of the deposit is:
For service performed through 12/31/98
(3% of your military basic pay).
For service performed from 1/1/99 through
12/31/99 (3.25% of your military basic pay).
For service performed from 1/1/00 through
12/31/00 (3.4% of your military basic pay).
For service performed from 1/1/01 to the present
(3% of your military basic pay).
Read the information about survivor benefits found in the
pamphlet, Applying for Immediate Retirement Under
FERS, before completing Section D.
If you are waiving military retired pay for FERS
retirement purposes, your agency can help you
prepare your request for waiver. Attaching a copy of
your waiver request and the military finance center's
acknowledgment (if available) to your application may
help us to process your claim more quickly. (Even if
you have already waived your military retired pay to
receive benefits from the Department of Veterans
Affairs, you also need to file a waiver for FERS.)
Section C - 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 certified copy of the court
order and any attachments or amendments.
Section D - Annuity Election
(See pages 13-20 of SF 3113, Applying for Immediate
Retirement Under the Federal Employees Retirement
System.)
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
acceptable 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.
You must pay the deposit to your agency while you are
still employed. You may not pay OPM after you retire.
If you are entitled to have part of your retirement
computed under CSRS rules, military service
performed prior to your transfer to FERS comes under
CSRS deposit rules. These rules are as follows:
The CSRS deposit is 7 percent of your military
basic pay.
If you were first employed in a civilian position
subject to CSRS coverage before October 1,
1982, you do not pay the deposit and you are
eligible for a Social Security benefit at age 62,
the CSRS part of your annuity will be
recomputed at age 62 to delete credit for the
post-1956 military service.
If you were first employed in a civilian position
subject to CSRS coverage on or after October 1,
1982, you will not receive any credit for
post-1956 military service if you do not make
the deposit for it.
CSRS military service deposits must also be paid
to your agency while you are still employed.
Item 5:If you are receiving, or have applied for, military retired
pay or benefits from the Department of Veterans Affairs
in lieu of military retired pay, answer "yes" to Item 5,
then complete and attach Schedule B-Military Retired
Pay. (Note: Military retired pay includes disability
retired pay and reserve retainer pay.)
This information is needed to assure correct credit for
military service. With limited exceptions, you must
waive your military retired pay to receive credit for your
military service in your FERS annuity.
You may receive credit in your FERS annuity for your
military service without waiving your military retired
pay if you are entitled to military retired pay awarded
for:
reserve service under Chapter 1223, title 10,
U.S. Code (formerly Chapter 67, title 10); or
a disability incurred in combat with an enemy of
the United States; or caused by an
instrumentality of war in the line of duty during
a period of war as defined by Section 1101 of
title 38.
Attach a copy of your retirement order from your
military service to this application. If applicable, also
attach a copy of your military service's determination
that your military disability retirement was service
connected and incurred in combat as described, or
caused by an instrumentality of war as described. Only
your military service branch can make this
determination; the Department of Veterans Affairs
cannot make this determination. If you do not have
verification of the type and conditions of your military
retirement, you should get the verification from the
retirement service organization of your military service
before you retire from your civilian position.
The law gives an alternate method to compute the
military deposit if an employee served on active duty,
and such service interrupted creditable civilian service
under subchapter I of chapter 84 of title 5, and was
followed by reemployment in accordance with chapter
43 of title 38 that occurs on or after August 1, 1990.
The employee pays no more than the amount of
retirement contributions that would have been withheld
from basic pay during civilian service if the employee
had not performed the period of military service.
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 pay 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 be
paid to your employing agency before you retire.
Please note that, in accordance with the law, both a survivor
annuity election made at retirement and a 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.
Box 4: If you initial Box 4, a person selected by you,
who has an insurable interest in you, will receive
a survivor annuity upon your death. Insurable
interest exists if the person named may reasonably
expect to derive financial benefit from your
continued life. A disabled child or a former
spouse are persons who might have an insurable
interest in you.
If you choose an insurable interest survivor
annuity, the survivor annuity will be 55 percent of
your annuity after your annuity has been reduced
to provide this benefit. The table below shows the
reduction percentages.
Any employee who is not retiring for disability
and who can prove good health may elect a
reduced annuity to provide a survivor annuity for
a person having an insurable interest in the
retiree.
You may elect this insurable interest survivor annuity
in addition to a regular survivor annuity for a current or
former spouse. 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.
If you choose an insurable interest 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 table
below.
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 to provide a survivor annuity for more
than one former spouse. The total of the survivor
annuities must equal either 25% or 50% of your
unreduced annuity.
If you are married, you must have your spouse's consent
to choose this option, because any benefit elected for a
former spouse limits what can be elected for your
current spouse. (Complete and attach SF 3107-2,
Spouse's Consent to Survivor Election, to your
application.) The maximum combined survivor benefits
that can be elected for your current and former spouse(s)
is 50% of your benefit.
Section E - Insurance Information
Item 1b: Indicate whether there is a court order or
administrative order currently in effect that
requires you to provide health benefits coverage
for your child(ren). If you answer "yes", you must
submit a copy of the court order or administrative
order.
Section F - Other Claim Information
Item 1:If you have applied for, or have ever received, workers'
compensation from the Office of Workers'
Compensation Programs, U.S. Department of Labor,
because of a job-related illness or injury, check the
"yes" box and complete Schedule C.
In Schedule C you should provide the following
information:
1.If you are receiving or have received
compensation, enter your compensation claim
number(s), the beginning and ending dates of each
period for which compensation was paid, and
whether the benefits were a scheduled award,
disability or other type of compensation.
2.If you have applied for, but are not receiving
benefits, indicate whether your claim is pending
or has been denied and the claim numbers
applicable.
3.Indicate whether you agree to notify us if the
status of your workers' compensation claim
changes and whether or not you authorize the
Office of Personnel Management and/or the
Office of Workers' Compensation Programs to
collect any overpayment if we find that you
were paid, but not eligible for, both compensation
and annuity benefits covering the same period of
time. Without this authorization from you, we
will not pay your annuity until we can confirm
that OWCP is not paying you compensation.
The information requested regarding benefits from
the Office of Workers' Compensation Programs is
needed because the law prohibits the dual compen-
sation which would exist if you received both a
FERS annuity and compensation for total or partial
disability under the Federal Employees' Compen-
sation Act.
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 who is over age 22 and incapable of self-support
because of mental or physical disability incurred before age 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 in the event of your death.
Standard Form 3107
3
Revised May 2014
Box 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.
Section H - Payment Instructions
Complete in all cases. The US 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 the 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.
Section I - Applicant's Certification
Be sure to sign (do not print) and date your application after
reviewing the warning.
Privacy Act Statement
Solicitation of this information is authorized by the Federal Employees Retirement law, (Chapter 84, title 5, U.S. Code), the Federal Employees Group Life Insurance
law (Chapter 87, title 5, U.S. Code) and the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code). The information you furnish will be used to
identify records properly associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future
benefits, and to maintain a unique identifiable claim file. 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 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 use of the Social Security Number. The Government may use your number in collecting and reporting amounts that you owe
the Government. Failure to furnish the requested information may delay or prevent action on your application. Information you provide about your unmarried
dependent children may be used to expedite their claims after you die; however, your failure to supply such information will not affect any future rights they may
have to benefits.
Standard Form 3107
4
Revised May 2014
See Privacy Act
Information on
Application for Immediate Retirement
Instruction Sheet
Federal Employees
Retirement System
Federal Employees Retirement System
Section B - Federal Service
1. Department or agency from which you are retiring (include bureau or division, address and ZIP code) 2. Date of final separation (mm/dd/yyyy)
3. Title of position from which you are
retiring
Section A - Identifying Information
3.
2.Name (last, first, middle) 1. List all other names you have used
Address (number, street, city, state, ZIP code)
4a. Daytime telephone # after retirement (including area
code)
4b. Best time to reach you
4c. Home email address 4d. FAX Number
5. Date of birth (mm/dd/yyyy) 6. Social Security Number
Are you a citizen of the United States of America? 8.
Yes
Yes (Ask your employing office about other documents you must submit)
7.
No No
Is this an application for disability retirement?
3a. Your pay plan and occupational series
4.Have you performed active honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definitions)?
Yes (Complete Schedule A and attach it to this form)
No
5.Are you receiving or have you applied for military retired pay? (Note: If you later become entitled to military retired pay you must notify OPM.)
Yes (Complete Schedule B and attach it to this form)
No
Section C - Marital Information (All applicants must complete questions 1 and 2 below.)
1.Are you married now? (A marriage exists until ended by death, divorce, or annulment.)
Yes (Complete items 1a - 1f and attach a copy of your marriage certificate)
No (Go to item 2)
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 performed by:
Clergyman or Justice of Peace
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?
Yes (Attach a certified copy of the court order[s] and any amendments.)
No
Section D - Annuity Election
Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested. Read the pamphlet SF 3113,
Applying for Immediate Retirement under FERS and the explanations below and consider your election carefully. No change will be permitted after your
annuity is granted except as explained in the pamphlet. If you are married at retirement, the law provides an annuity with full survivor benefits for your spouse
unless your spouse consents to your election not to provide maximum survivor benefits.
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.
1.
I choose a reduced annuity with maximum survivor annuity for my spouse named in Section C. If you are married at retirement,
you will 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%. Your spouse's annuity upon your death will be 50% of your unreduced
earned annuity.
Initials
2.
I choose a reduced annuity with a partial survivor annuity for my spouse named in Section C. 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 earned annuity. You must
have your spouse's consent to choose this option. Complete form SF 3107-2, Spouse's Consent to Survivor Election, and attach it to
your application.
Initials
3.
I choose an annuity payable only during my lifetime. If you are married at retirement, you cannot choose this type of annuity
without your spouse's consent. No survivor annuity will be paid to your spouse after your death if he or she consents to this
election and any health benefits will cease. 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. If you are married and elect this, complete form SF 3107-2,
Spouse's Consent to Survivor Election, and attach it to your application.
Initials
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.
3107-108
Standard Form 3107
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous editions are not usable.
Revised May 2014
4.
Initials
I choose a reduced annuity with survivor annuity for the person named below who has an insurable interest in me. You must be
healthy and willing to provide medical evidence if you choose this type of annuity. (Disability annuitants are not eligible to choose
this type of annuity.) If you are married and elect this option for your spouse, complete SF 3107-2, Spouse's Consent to Survivor
Election and attach it to your application.
Name of person with insurable interest Relationship to you Date of birth (mm/dd/yyyy) Social Security Number
5.
Initials
I choose a reduced annuity with survivor annuity for my former spouse(s) as follows: You must attach: (1) Copies of divorce
decrees for all former spouses for whom you elect to provide a survivor annuity. (2) If you are married, attach a completed
SF 3107-2, 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.
Name and address of former spouse
Survivor annuity equal
to _______________%
of my annuity
Date of marriage
(mm/dd/yyyy)
Date of divorce
(mm/dd/yyyy)
Date of birth
(mm/dd/yyyy)
Social Security Number
Name and address of former spouse
Survivor annuity equal
to _______________%
of my annuity
Date of marriage
(mm/dd/yyyy)
Date of divorce
(mm/dd/yyyy)
Date of birth
(mm/dd/yyyy)
Social Security Number
Total (either 25% or 50% of your unreduced annuity)
_______________%
Section E - Insurance Information
Are you eligible to continue Federal Employees Health Benefits coverage as a
retiree?
1a.
Yes No
See the pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System,
for information.
Is there a court order or administrative order currently in effect that requires
you to provide health benefits coverage for your child(ren)?
1b.
Yes (Attach a copy of the court/administrative order) No
2.Are you eligible to continue Federal Employee's Group Life Insurance coverage as a retiree?
Yes No
3. Are you enrolled in the Federal Dental and Vision Insurance Program (FEDVIP)?
Yes
Your coverage will automatically continue into retirement as long as you continue to pay applicable premiums. Until work on your
annuity is completed, you may receive bills from BENEFEDS. You must pay these bills in order to keep your FEDVIP coverage.
After work on your annuity is completed, BENEFEDS will automatically begin deducting from your annuity to pay future premiums.
If you have questions, please contact BENEFEDS at 1-877-888-3337.
No
If you retire on an immediate annuity, you can enroll in FEDVIP during any Federal Benefits Open Season.
4. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?
Yes
You will automatically continue your coverage into retirement, as long as you continue to pay applicable premiums. If you are currently
paying FLTCIP premiums by agency payroll deduction, you must arrange to pay premiums another way, either by deductions from your
annuity, through automatic bank debit or direct bill. Please call LTC Partners at 1-800-LTC-FEDS (1-800-582-3337) to make these
arrangements.
No
Section F - Other Claim Information
1.Have you applied for, are you receiving, or have you ever received workers' compensation from the Department of Labor because of a job-related illness or injury?
Yes (Complete Schedule C and attach it to this form)
No
2. Have you previously filed any application under the Civil Service Retirement System or Federal Employees Retirement System (for retirement, refund, deposit or redeposit,
or voluntary contributions)?
Yes (Complete items 2a and 2b below.)
No
Type of application 2a.
Retirement
Refund
Return of excess deductions
Deposit or redeposit
Claim number(s)2b.
Section G (Optional) - Information About Your Unmarried Dependent Children
Dependent child's name
(first, middle, last)
1.
2.
Date of birth
(mm/dd/yyyy)
Disabled
(
)
3.
Dependent child's name
(first, middle, last)
1. 2.
Date of birth
(mm/dd/yyyy)
Disabled
(
)
3.
Voluntary contributions
3107-107
Standard Form 3107
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous editions are not usable.
Revised May 2014
Section H - Payment Instructions
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 the Treasury. See the instructions for Section H of this application and SF 3113 (Applying for Immediate Retirement Under the Federal
Employees Retirement System) for additional information. This does not apply to you if your permanent payment address is outside 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 item 3a)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to item 3a)
You may obtain this number by calling your bank, credit union, or savings institution.
This number is very important. We cannot pay by direct deposit without it.
Financial Institution Routing Number 2a.
Checking or Savings Account Number 2b. Telephone number of your Financial Institution (including area code)2d.
Special Note: If you prefer, you may attach a cancelled personal check that
shows the information requested above, 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 the correct
information for direct deposit. (Some institutions, especially credit unions,
use different routing numbers on checks.) We can then use this information
to start paying you by direct deposit.
2e. Name and address of Financial Institution
Do you want Federal income tax withheld from your annuity payments? 3a. Do you want to have Federal Income Tax withheld at the rate currently being
withheld from your salary?
3b.
Yes (Go to item 3b) No (Go to Section I)
Yes (Attach copy of W-4 form on file with your employing agency.)
No (Attach new W-4 form, otherwise withholding will be at rate for
married with 3 exemptions.)
Section I - Applicant's Certification
Warning
Any intentionally false statement in this
application or willful misrepresentation relative
thereto 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)
I hereby certify that all statements made in this application are true to the best of my knowledge and belief.
Date (mm/dd/yyyy)Signature (Do not print)
Applicant's Checklist
This checklist is provided to help you be certain you have attached all necessary documentation and to help your employing office be
certain it forwards all of your retirement documentation to the Office of Personnel Management.
No
Military Service - If you completed Schedule A, did you attach a copy of your discharge certificate or other certificate of
active military service?
2.
Military Service - If you answered "yes" to Section B, Item 4, did you attach Schedule A? 1.
Military Retired Pay - If you answered "yes" to Section B, Item 5, did you attach Schedule B? 3.
Military Retired Pay - If you completed Schedule B and answered "yes" to Item b or c, did you attach a copy of the notice
of award or other documentation of the type of military retired pay you are receiving?
4.
Military Retired Pay - If you completed Schedule B and answered "yes" to item d, did you attach a copy of your request
for waiver and a copy of the military finance office's acknowledgment or approval of your request for waiver (if applicable)?
5.
Survivor Election - If you are married and did not initial box 1 of Section D, did you attach SF 3107-2, Spouse's Consent
to Survivor Election?
6.
Life Insurance - If you answered "yes" to Section E, item 2, did you attach SF 2818, Continuation of Life Insurance Coverage
As an Annuitant or Compensationer?
7.
OWCP - If you answered "yes" to Section F, item 1, did you attach Schedule C? 8.
Tax - If you want to elect a Federal Income Tax withholding rate, did you attach a W-4 form? 9.
What kind of account is this? 2c.
Checking Savings
Yes Not
Applicable
Court or Administrative Order(s) - If you answered "yes" to Section C, item 2 and/or "yes" to Section E, Item 1b, did you attach
a copy of the order(s)?
10.
3107-108
Standard Form 3107
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous editions are not usable.
Revised May 2014
Schedules A, B and C
Name (last, first, middle) 1. Date of birth (mm/dd/yyyy)2. Social Security Number 3.
Schedule A - Military Service Information
1.If you have performed active honorable service in the United States Armed Services or other uniformed services, complete 1a - d below and attach a copy of your discharge
certificate or other certificate of active military service (if available).
See instructions for definitions of Armed Services and Uniformed Services.
a.
Branch of service Serial number
b.
Dates of active duty
c.
Last grade or
rank
d.
From (mm/dd/yyyy) To (mm/dd/yyyy)
2.If any of your military service occurred on or after January 1, 1957, have you paid a deposit to your agency for this service? (You must pay this deposit to your agency.
You cannot pay OPM after you retire.)
YesNo
Schedule B - Military Retired Pay
1.
If you are receiving or have applied for military retired or retainer pay (including disability or retired pay), complete Parts 1a - 1d below.
a. Are you receiving or have you ever applied for military retired or retainer pay?
(Answer "yes" if you are receiving payments from the Department of Veterans
Affairs instead of military retired pay.)
Yes No
Was your military retired or retainer pay awarded for reserve service under
Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10)?
b.
Yes (Attach a copy of notice of award) No
c. Was your military retired pay or retainer pay awarded for a disability incurred
in combat or caused by an instrumentality of war and incurred in the line of
duty during a period of war?
Yes (Attach a copy of notice of
award)
No
Are you waiving your military retired or retainer pay in order to receive credit
for military service for FERS retirement benefits?
d.
Yes (Attach a copy of your request for
waiver and a copy of military finance
officer's acknowledgment or approval of
your request for waiver)
No
Schedule C - Federal Employees Compensation Information
1.Are you receiving or have you ever received workers' compensation from the Office of Workers' Compensation Programs (OWCP), Department of Labor, because of a
job-related illness or injury?
Yes (complete parts 1a - c below) No (go to question 2)
Compensation claim number
a.
Benefit received
b.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Type of benefit
c.
Scheduled award
Total or partial disability compensation
Scheduled award
Total or partial disability compensation
Other
Other
2.If you have applied for workers' compensation (other than as listed in item 1a above) but are not receiving benefits, check reason below and give the information requested.
a. Awaiting OWCP decision b. Claim denied
Compensation claim number
Compensation claim number Date claim denied (mm/dd/yyyy)
3.Except for scheduled compensation awards, workers' compensation and FERS retirement benefits cannot be paid for the same period of time. Please complete the
information below regarding your claim. You must complete this section.
a.Do you agree to notify us promptly if the status of your workers' compensation claim changes?
YesNo
b.Do you authorize the Office of Personnel Management and/or the Office of Workers' Compensation Programs (OWCP) to collect any overpayment if we later find you
are not eligible for both compensation and annuity payments covering the same period of time?
Yes No
Applicant's Certification
I certify that all statements made on
these schedules are true to the best
of my knowledge and belief.
Signature (do not print) Date (mm/dd/yyyy)
3107-108
Standard Form 3107
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous editions are not usable.
Revised May 2014
Office of Personnel
Management
Certified Summary of Federal Service
5 CFR Part 841
Federal Employees
Retirement System
Federal Employees Retirement System
Information for the Agency
1.A certified copy of this form must accompany the employee's
Application for Immediate Retirement (SF 3107).
2.
This form may also be used:
for retirement counseling purposes
to respond to an employee's request for a record of creditable
service
3.
See the CSRS and FERS Handbook for Personnel and
Payroll Offices for detailed instructions for completion and
disposition of this form.
Instructions for the Employee
1.Your employing office will complete and certify this form for you.
2.Review this form carefully. Be sure it contains all of your service.
3.Complete Section E, Employee's Certification, and return the form
to your employing office.
Section A - Identification
Name of employee (last, first, middle) 1. Date of birth (mm/dd/yyyy)2. Social Security Number 3.
Other birth dates used5. Military serial number 6.
Service computation date for retirement purposes 7.
List all other names used (maiden name, AKA, spelling variants) 4.
Did this employee elect to transfer to FERS? 8a.
No Yes, give effective date of election:
If the employee elected to transfer to FERS, is the employee entitled, according to
your records, to have part of the FERS annuity computed under CSRS rules?
8b.
Does the applicant receive military retired pay? 9a. If yes, has the applicant waived military retired pay to credit military service for
FERS retirement?
9b.
Yes (Attach a copy of the applicant's military retired pay order,
if available, and complete 9b.)
Yes (Attach a copy of the military finance center's letter to the
employee accepting waiver, if available.)
No No (Include cases where a waiver is not necessary.)
Section B - Verified Service History Documented in Official Personnel Records
Federal agency or
military service branch
Appointment, separation, or conversion
dates for civilian and active honorable
military service
Name of retirement
system*
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Remarks and non-creditable time**
Yes No
* Give details of creditable civilian service not subject to retirement deductions in Section C.
**In Remarks, show if CSRS service on or after January 1, 1984, is "regular" CSRS or CSRS Offset.
Indicate if service is part-time. If service was performed on a WAE or intermittent basis, show the number of days worked in "Remarks." If the number of days worked is not
available, then show the number of hours worked.
3107-108
Standard Form 3107-1
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous editions are not usable.
Revised May 2014
Section C - Detail of Civilian Service Not Subject to Contributory Retirement System for Civilian
Federal Employees
Detail below (1) any period of Federal civilian service subject only to "FICA" deductions, and (2) any other Federal civilian service not subject to a Federal
employee (or D.C. Government) retirement system. If total basic salary earned for any such period of service is known, you may make a summary entry on
the right hand side below. Otherwise, show each change affecting basic salary during the period of service. Show part-time tour of duty, if applicable. Also
provide total number of hours the employee worked during the period of part-time service, if available, and show what a full-time tour of duty would be.
Service which is not subject to FERS or CSRS deductions is creditable only as specifically allowed by law.
Nature of action
(Appt., pro.,
res., etc.)
Effective date
(mm/dd/yyyy)
Basic
salary rate
Salary basis
(per annum,
per hour,
WAE, etc.)
Leave
without pay
If basic salary actually earned is available
make summary entry below
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Total earned
Section D - Agency Certification
I certify that the information on this form accurately reflects verified information contained in official records and that the applicant has sufficient service to be
entitled to an annuity. I further certify that all required documentation in support of this application is attached, accurate and complete.
Signature of authorized agency personnel official Agency name and address, including ZIP Code, telephone number (including
area code), FAX number, and EMAIL address
Official Title Date (mm/dd/yyyy)
Section E - Employee's Certification
The service listed is complete.
I have additional service. (If you claim additional service, attach signed statement(s) giving dates, positions, titles and locations of employment,
including agency, bureau, and division. Claimed service cannot be credited for retirement until it has been verified. This includes unverified service
listed on an SF 144, Statement of Prior Federal Civilian and Military Service, or similar affidavit.)
Note:If you have performed Federal civilian service subject to social security deductions (FICA) or not subject to retirement deductions, be sure that
your agency has correctly completed Section C above.
Signature (do not print) Date (mm/dd/yyyy)
3107-108
Reverse of Standard Form 3107-1
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous editions are not usable.
Revised May 2014
Spouse's Consent to Survivor Election
Instructions: If you are married and you do not elect a reduced annuity to provide a maximum survivor annuity for your current spouse,
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 person administering oaths must complete Part 3.
Part 1 - To Be Completed by the Retiring Employee
Name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
I have elected: (Mark the box(es) which describes the survivor election(s) you have made. More than one box may be marked.)
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,
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.An insurable interest annuity for my current spouse, but no regular survivor annuity for my current spouse. (I have completed Section D, item 4 on
my Standard Form 3107 naming my current spouse.)
d.A maximum survivor annuity for my former spouse _________________________________________________________.
c.A partial survivor annuity (25%) for my current spouse.
(name of former 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)
Part 2 - To Be Completed by the Current Spouse of the Retiring Employee
I freely consent to the survivor annuity election described in Part 1. I understand that if my spouse elected no regular or insurable interest survivor annuity
in Part 1.a. above, I will not receive a survivor annuity, my health benefits coverage will terminate and I will not be eligible to enroll in the Federal Long
Term Care Insurance Program (FLTCIP) if I am not already enrolled before my spouse's death. I also understand that my consent is final (not
revocable).
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
acknowledged that the consent was freely given in my presence on this
the __________ day of _________________________, __________, at _______________________________________________________.
(Month) (Year)(City and State)
Signature (do not print)
(Seal of Notary Public or witnessing authority of person authorized to administer oaths)
(Seal)
Expiration date (mm/dd/yyyy) of commission, if Notary Public
General Information: The law requires that a retiring, married employee
must elect to provide a survivor annuity for a current spouse, unless the
current spouse consents to an election not to provide the maximum
survivor benefit.
A court order which requires a retiring employee 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 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 remarriage before age 55 or death).
Important: If the current spouse consents to an election to provide no
survivor annuity or a partial survivor annuity and is later divorced from the
retired employee, the retired employee may not then elect (nor can OPM
honor a court order) to provide a former spouse annuity which exceeds the
amount elected at retirement for that spouse. This also applies if the parties
remarry.
Privacy Act Statement
Solicitation of this information is authorized by the Federal Employees Retirement law, (Chapter 84, title 5, U.S. Code), the Federal Employees Group Life Insurance law (Chapter 87, title 5, U.S. Code)
and the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your application for Federal
benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a unique identifiable claim file. 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 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 use of the
Social Security Number. The Government may use your number in collecting and reporting amounts that you owe the Government. Furnishing the Social Security Number, as well as other data, is
voluntary, but failure to do so may delay or prevent action on the retirement application.
3107-108
Standard Form 3107-2
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous editions are not usable.
Revised May 2014
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