Fillable Printable Sf3106
Fillable Printable Sf3106
Sf3106
Continue on Reverse
(You MUST complete both sides of this application)
U.S. Office of Personnel Management
5 CFR 843
SF 3106
Revised March 1996
Previous editions are not usable
NSN 7540-01-249-5576
3106-104
See the attached sheets for instructions and
information concerning your application for
refund of retirement deductions and a
Privacy Act Statement.
Form Approved:
OMB Number 3206-0170
Application For Refund of Retirement Deductions
Federal Employees Retirement System
To avoid delay in payment:
(1) Complete both sides of application in full; (2) Typewrite or print in ink.
6.List below allof your civilian and military service for the United States Government. Attach a continuation sheet with your name and Social Security Number if necessary.
Department or Agency
(Including bureau, branch, or division
where employed.)
Location of Employment
(City, State and ZIP Code)
and Payroll Office Number
(if known)
Title of Position
(and indicate if the
position was civilian [c]
or military [m])
Periods of Service
Indicate whether
retirement
deductions were
withheld from your
salary.
(Check One)
Have you paid
deposit for any
period including
military service?
(Check One)
Beginning
Date (mo./yr.)
Ending
Date(mo./yr.)
Withheld
Not
Withheld
Not Paid
Fully or
Partially
7.
APPLICANT CERTIFICATION: I understand that I am not legally entitled to receive a refund if I am reemployed or otherwise assigned to a position under the
Federal Employees Retirement System or Civil Service Retirement System within 31 days of separating from my most recent position. I agree to notify OPM if I am
employed again within this time period and to return or repay any refund paid to me if it is determined that I was not legally entitled to that refund.
I understand that payment of a refund will result in permanent forfeiture of any retirement rights that are based on the period(s) of Federal Employees
Retirement System service which the refund covers, as explained in this package.
I hereby certify that all statements in this application, including any information I have given elsewhere in this form, are true to the best of my belief and knowledge
and that the tax withholding election made here reflects my wishes.
SignatureDate (mo./day/yr.)
3. Social Security Number
4. List all other names you have used (including maiden name, if applicable.)
1. Name (last, first, middle)2. Date of birth (mo./day/yr.)
5. Address for mailing refund check (number and street, city, state and ZIP Code)- We cannot authorize payment if this address is erased or otherwise changed.
Telephone number (including area code)
( )
8. Have you accepted any further employment with the Federal government or the Government of the District of Columbia (or arranged for such employment) to become effective within 31 days from the ending date of your
last period of service?
For agency use only: I certify that this agency received this Standard Form 3106 on the date shown.
Signature of agency official
Title
Date received (mo./day/yr.)
Agency Payroll Office number
Are you now married? If "Yes," complete SF 3106A, Current/Former Spouse's Notification of Application for Refund of Retirement Deductions, or other required information described in this package.13.
14.Have you been divorced?
No
Yes. If your answer is "yes" and you have a total of at least 18 months of creditable civilian service, complete an SF 3106A (attached) for each living former spouse to whom you were
married for at least 9 months. List the former spouses in the space given below.
Yes, list the name of your current spouse:
12. Indicate how you wish to have Federal income tax withheld from the interest portion of your refund. Please refer toSpecial Tax Notice Regarding Rolloversin this package before making your decision. Since the
amount of your interest is calculated after we receive your application, please make one choice in bothPart A (if the interest portion is under $200)and in Part B (if the interest portion is greater than $200).
Part AIf my total interest is less than $200.
Withhold Federal income tax from the interest portion of my refund payment. (In this instance, 10% of the interest will be withheld.)
Do not withhold Federal income tax from the interest portion of my refund payment.
I elect to have my interest computed and a rollover package with all my options sent to me before I decide how the interest portion should be paid. (Electing this option delays
payment of your refund at least an additional 30 days.)
Part BIf my total interest is $200 or greater.
I elect to have all of the taxable portion paid to me, less 20% Federal income tax withholding.
I elect to rollover the interest portion into an IRA. My financial institution or retirement plan has completed the financial institution certification form. (See next page.)If you want
the rollover amount sent to your mailing address so you can personally deposit it into your IRA, check here: [ ] (In this case, we will make the check payable to your IRA
Account in care of your address.)
Reverse of SF 3106
Revised March 1996
No, skip items 9, 10, and 11. Continue with item 12.Yes, continue with item 9.
9. If you answered "Yes" to Item 8, are Federal Employees' Retirement System or Civil Service Retirement
System deductions being withheld from your salary during such employment?
10. Date of new appointment.(Expected date if not yet reemployed.)
YesNo
11. Department or agency, including bureau, or division, and location (City, State, ZIP Code) where you are (or will be) employed.
Warning:Any intentional 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)
Name of former spouseDate of marriageDate of divorce
No
This notice contains important Federal income tax and other information
you will need before you decide how to receive your lump sum payment
from the Federal Employees’ Retirement System (FERS). To be of service to
our customers, the Office of Personnel Management has worked with the
Internal Revenue Service to present a general explanation of how Public
Law 102-318 affects those who receive our benefits. However, the IRS
remains the authority on tax matters and questions. Requests for
additional or clarifying information should be directed to them. The official
tax publications which govern how benefits are taxed are referenced at the
end of this notice. OPM does not stock IRS publications. We cannot provide
official tax information nor can we advise individuals on tax matters. The
following discussion applies to the taxable portion of your lump sum
payment.
Sum mary
The interest portion of your refund payment from OPM is taxable and is
eligible for “rollover.” You can have all or any part of your interest payment
either 1) paid in a “direct rollover” or 2) paid directly to you. A rollover is
a payment of the taxable portion of your FERS benefit to your individual
retirement arrangement (IRA) or to another employer retirement plan. This
choice will affect the tax you owe.
If you choose a direct rollover of the interest —
•Your in ter est will not be tax able in come in the year it is paid, and no
in come tax will be with held.
•Your in ter est pay ment will be made di rectly to your IRA, or, if you
choose, to an other em ployer re tire ment plan that ac cepts your
rollo ver.
•Your in ter est pay ment will be tax able in come later when you take it
out of the IRA or the em ployer re tire ment plan.
If you choose to have the interest paid to you —
•You will receive only 80% of the interest, because OPM is required to
withhold 20% of the payment and send it to the Internal Revenue
Service as income tax withholding to be credited against your taxes.
•Your interest will be taxed in the year it is paid unless you roll it over.
You may be able to use special tax rules that could reduce the tax you
owe. However, if you receive the payment before age 59½, you also
may have to pay an additional 10% tax.
•You can roll over the interest by paying it to your IRA or to another
employer retirement plan that accepts your rollover within 60 days
after you receive the payment. The amount rolled over will not be
taxed until you take it out of the IRA or employer retirement plan.
•If you want to roll over 100% of the interest to an IRA or an employer
retirement plan, you must find other money to replace the 20% that
was withheld. We cannot refund the 20% once it has been withheld. If
you roll over only the 80% you receive, you will be taxed on the 20%
that was withheld and not rolled over.
More In for ma tion
I. Pay ments That Can and Can not Be Rolled Over
Certain payments from OPM are “eligible rollover distributions.” This
means they can be rolled over to an IRA or to another employer retirement
plan that accepts rollovers. In general, only the “taxable portion” of your
payment is an eligible rollover distribution. The following types of
payments cannot be rolled over:
Non-taxable Payments. In general, the non-taxable portion of your
payment is not an eligible rollover distribution. Your retirement
contributions are non-taxable when they are paid to you and cannot be
rolled over.
Required Minimum Payments. Beginning in the year you reach age 70½,
a certain portion of your payment cannot be rolled over because it is a
“required minimum payment” that must be paid to you. You must compute
and exclude this amount from a direct rollover if you will be age 70½ or
older when the payment is made.
II. Di rect Rollo ver
You can choose a direct rollover of all or any portion of the interest portion
of your refund. In a direct rollover, the eligible rollover distribution is paid
directly from OPM to an IRA or another employer retirement plan that
accepts rollovers (or is sent to you in a check made payable to the IRA or
other retirement plan). If you choose a direct rollover, you are not taxed on
the payment until you later take it out of the IRA or the employer
retirement plan.
OPM will not pay a direct rollover or withhold tax on taxable payments
under $200, but recipients themselves may roll over such payments tax
free within 60 days after receipt. The minimum direct rollover amount is
$500 if you designate part of your payment as a direct rollover with the
remainder payable to you. OPM will pay a direct rollover to only one IRA or
retirement plan at any one time.
Direct Rollover to an IRA. You can open an IRA to receive the direct
rollover (The term “IRA,” as used in this notice, includes individual
retirement accounts and individual retirement annuities.) If you choose to
have your payment made directly to an IRA, contact an IRA sponsor
(usually a financial institution) to find out how to have your payment made
in a direct rollover to an IRA at that institution. If you are unsure of how to
invest your money, you can temporarily establish an IRA to receive the
payment. However, in choosing an IRA, you may wish to consider whether
the IRA you choose will allow you to move all or part of your payment to
another IRA at a later date, without penalties or other limitations. See IRA
Publication 590, Individual Retirement Arrangements, for more
information on IRAs (including limits on how often you can roll over
between IRAs).
Direct Rollover to an Employer Retirement Plan. If you are employed
by a new employer that has a retirement plan and you want a direct
rollover to that plan, ask the administrator of that plan whether it will
accept your rollover. An employer retirement plan is not legally required to
accept a rollover. If your new employer’s retirement plan does not accept a
rollover, you can choose a direct rollover to an IRA.
III. Pay ment Paid to You
If you have the interest payment made to you, it is subject to 20% Federal
income tax withholding. The payment is taxed in the year you receive it
unless, within 60 days after receiving it, you roll it over to an IRA or
another plan that accepts rollovers. If you do not roll it over, special tax
rules apply.
Mandatory Federal Income Tax Withholding. If you receive interest,
OPM is required by law to withhold 20% of that amount. This amount is
sent to the IRS as income tax withholding. For example, if your interest
payment is $3000, only $2400 will be paid to you because OPM must
withhold $600 as income tax. However, when you prepare your income tax
return for the year, you will report the full $3000 as interest on your
refund. You will report the $600 as tax withheld, and it will be credited
against any income tax you owe for the year.
Sixty-Day Rollover Option. You can still decide to roll over all or part of
the interest payment to an IRA or another employer retirement plan that
accepts rollovers within 60 days after you receive the payment. The portion
of your payment that is rolled over will not be taxed until you take it out of
the IRA or the employer retirement plan.
You can roll over up to 100% of the interest payment, including an amount
equal to the 20% that was withheld. If you choose to roll over 100%, you
must find other money within the 60-day period to contribute to the IRA or
the employer retirement plan to replace the 20% that was withheld. On the
other hand, if you roll over only the 80% that you received, you will be
taxed on the 20% that was withheld.
Example: If your interest payment is $3000, and you choose to have it
paid to you, you will receive $2400 and $600 will be sent to the IRS as
income tax withholding. Within 60 days after receiving the $2400, you may
roll over the entire $3000 to an IRA or employer retirement plan. To do
this, you roll over the $2400 you received from OPM, and you will have to
find $600 from other sources (your refund, savings, a loan, etc.). In this
case, the entire $3000 is not taxed until you take it out of the IRA or
employer retirement plan. If you roll over the entire $3000, when you file
your income tax return you may get a refund of the $600 withheld.
If, on the other hand, you roll over only $2400, the $600 you did not roll
over is taxed in the year it was withheld. When you file your income tax
return, you may get a refund of part of the $600 withheld. (However, any
tax refund is likely to be larger if you roll over the entire $3000.)
Additional 10% Tax If You Are Under Age 59½.
If you receive a payment
before you reach age59½ and you do not roll it over, then, in addition to
the regular income tax, you may have to pay an extra tax equal to 10% of
the interest payment. The additional 10% tax does not apply to your
payment if it is (1) paid to you because you separate from service with your
employer during or after the year you reach age 55, (2) paid because you
retire due to disability (as determined by IRS), (3) paid to you as equal (or
almost equal) payments over your life or life expectancy (or you and your
beneficiary’s lives or life expectancies), or (4) used to pay certain medical
expenses. See IRS Form 5329,Return for Additional Taxes..., for more
information on the additional 10% tax.
How To Ob tain Ad di tional In for ma tion
This notice summarizes only the Federal (not State or local) tax rules that
might apply to your payment. The rules described above are complex and
contain many conditions and exceptions that are not included in this
notice. Therefore, you may want to consult with a professional tax advisor
before you take a payment of your refund from OPM. Also, you can find
more specific information on the tax treatment of payments from qualified
retirement plans in IRS Publication 575,Pension and Annuity Income,
IRS Publication 590, Individual Retirement Arrangements, and IRS
Publication 721,Tax Guide to U.S. Civil Service Retirement Benefits.
These publications are available from your local IRS office or by calling
1-800-TAX-FORMS.
Special Tax Notice Regarding Rollovers
Spe cial In for ma tion for Ap pli cant
1.You must complete all questions 1 through 14 on the refund
application. Additionally, your financial institution must complete the
certification if you elect to roll over the interest payable into an IRA.
Your current and/or living former spouse(s) must each complete a
separate SF 3106A to document notification of your application if you
are or have been married.
2.Payment of a refund of your Federal Employees Retirement System
(FERS) deductions will permanently eliminate your retirement rights
for the period(s) of FERS service which the refund covers. You will not
be permitted to pay the money back, even if you are later reemployed
in the government. The service involved cannot be used in computing
annuity benefits that you may later become entitled to receive under
FERS nor can it be used in determining length of service for annuity
eligibility purposes. Payment of the refund will end eligibility any
former spouse(s) may have to coverage under the Federal Employees
Health Benefits Program. Payment of the refund does not, however,
affect credit for leave or other non-retirement purposes.
3.A refund of retirement deductions is usually paid within one month of
receipt of the application at OPM unless information is missing that is
needed to process the application. It cannot be paid prior to 31 days
after the date of separation from a position subject to FERS or Civil
Service Retirement System (CSRS) or within 31 days before the
earliest commencing date of any annuity for which you are eligible,
including an annuity which must be reduced for age.
Payment of a refund is prohibited if you are currently employed in a
position subject to FERS or CSRS deductions or will be eligible to
retire within 31 days from the date of OPM’s receipt of the refund
application.
4.Interest will be paid on your FERS refund at the same rate earned by
government securities if the period(s) of service which the refund
covers totals more than one year.
5.For additional information about your benefits if you decide not
to apply for this refund, see the bookletFERS (RI 90-1), which is
available from your agency.
6.Do not offer this application to a person or a financial institution as
collateral or security for a loan. A former employee must apply for a
refund personally and payment must be made directly to him or her
(except direct rollovers, as described in the Federal Tax Information
section). However, outstanding debts to the U.S. Government can, at
the Government’s request, be withheld from a refund, provided all
legal requirements are met.
Trans fers to FERS
Completion of this application will authorize OPM to refund all retirement
deductions to your credit under both FERS and CSRS. Any interest payable
is computed using the rules for the retirement system under which the
deductions are credited.
If you have deductions creditable under CSRS and receive a refund, you
can pay back the amount of the CSRS deductions plus interest if you are
later reemployed in the Federal government. The CSRS service can be used
in determining length of service for annuity eligibility even if you do not
repay the money. If you want only a refund of your CSRS deductions and
not your FERS deductions, attach a signed statement to your completed
application.
For additional information, see the FERS Transfer Handbook (RI 90-3)
which is available from your agency.
Fed eral Tax In for ma tion
Applicants are permitted to roll over the interest from their refund of
retirement contributions to an individual retirement arrangement (IRA) or
another retirement plan. If OPM pays the interest to you, 20% Federal
income tax must be withheld. (The non-taxable amount of your payment,
the actual contributions, can only be paid to you and cannot be rolled
over.)
If the interest payable in your refund is less than $200, we are not
required to withhold 20% for Federal income tax and we cannot roll over
any of the taxable amount. You can still roll over an amount equal to the
interest on the refund personally after we send the payment to you.
You must complete both Part A and Part B of Question 12 on the refund
application, instructing us how to pay any interest you may be due to
receive. Part A tells us how to pay your interest if it turns out that it is less
than $200. In Part B you tell us how to pay your interest if it turns out to
be $200 or more. Since we cannot tell you how much your interest will be
until we receive your application and complete the calculation, you can
instruct us to prepare an election form telling you the amount of interest
you can roll over (if it is over $200) after we compute the benefit. If you ask
for this detailed information, your case will be held until we send and
receive your written election, usually a delay of payment of at least 30 days.
If under Part B on Question 12 you elect to roll over the interest portion
into an IRA, your financial institution or retirement plan must complete
the certification printed below, before we can process your election.
More information is given in the Special Tax Notice Regarding Rollovers
on the reverse of this page. Consult a qualified tax advisor or the Internal
Revenue Service if you need more information on tax matters. OPM cannot
provide you with tax publications or tax advice.
If you do not complete an election in Question 12, Part A, we will pay your
interest directly to you and will withhold 10% for Federal income tax. If you
do not complete an election in Part B, we will pay your interest directly to
you and will withhold 20% for Federal income tax. You have the option to
roll over part or all of the interest yourself within 60 days after you receive
the payment.
Pri vacy Act State ment
Title 5, U.S. Code, Chapter 84, Federal Employees Retirement System,
authorizes solicitation of this information. The data you furnish will be
used to determine your eligibility to receive a refund of retirement
deductions. This information may be shared with national, state, local or
other charitable or social security administrative agencies to determine and
issue benefits under their programs, or with law enforcement agencies
when they are investigating a violation or potential violation of the civil or
criminal law. Executive Order 9397 (November 22, 1943) authorizes use of
the Social Security number to distinguish you and people with similar
names. Furnishing your Social Security number, as well as other data, is
voluntary, but if you do not do this, OPM may be unable to determine your
eligibility to receive a refund of retirement deductions.
Where to File Your Ap pli ca tion
1.If you have been separated 30 days or less, this application should be
forwarded to the office in which you were last employed. If you need to
check on the status of your application, first verify that your former
agency has sent it, along with your records, to OPM.
2.If you have been separated more than 30 days, forward this
application to the Office of Personnel Management, Federal Employees
Retirement System, P.O. Box 200, Retirement Operations Center,
Boyers PA 16017.
3.
If you want to withdraw your Thrift Savings Plan account balance, ask
your agency for information. This is not the form you would use.
Pub li c Bur den State ment
We think this form takes an average 27 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 Reports and Forms Management Officer, U.S. Office
of Personnel Management, 1900 E Street NW, Washington, DC 20415.
Instructions For Completion of Your Application For Refund of Retirement Deductions
Cer ti fi ca tion By Fi nan cial or Re tire ment Plan
If Applicant Elects to Roll Over Interest Paid with a Refund of Retirement Deductions
This must be completed by your financial institution or retirement plan.
Name of applicantSocial Security number
Name of institution or retirement planIRA Account numberAddress of institution or retirement plan
Certification: As a representative of the financial institution or plan named above, I confirm the account
number for the individual named above and the address. I certify that the financial institution orplan
named above agrees to receive funds from the individual and deposit them in an eligible IRA or
retirement plan as defined in the Internal Revenue Code.
Typed or printed name of certifying representativeDaytime phone number(including area code)
Signature of certifying representativeDate of certification(mo./day/yr.)
