Fillable Printable Standard Form 2812-A
Fillable Printable Standard Form 2812-A
Standard Form 2812-A
Form Approved
OMB 3206-0262
Report of Withholdings and Contributions for Health Benefits Interagency Report
Life Insurance and Retirement No. 1064-OPM-AR
FROM: Address (including Department, Bureau, Location, and ZIP Code) Payroll Office Number Report Number
Month reported on Statement of Transactions Date Payroll Paid
PAY PERIOD
From To
Telephone number (including area code)
To: OFFICE OF PERSONNEL MANAGEMENT I certify that the items listed herein are correct and the amount is available to
ATTN: FUNDS MANAGEMENT be credited to the OPM receipt account.
POST OFFICE BOX 582 Signature of authorized Administrative or Certifying Officer Date
WASHINGTON, DC 20044-0582
Benefit Category Withholdings Contributions Total
LIFE INSURANCE
Basic Life
Standard - Option A
Additional - Option B
Family - Option C
Post-Retirement
Total Life Insurance
HEALTH BENEFIT
S
Regular
Temporary Continuation of
Coverage (TCC) - P.L. 100-654
Total Health Benefits
RETIREMENT
CSRS
All Categories
1
Salary Offset - Reemployed
Annuitants
Military and Civilian Service Credit
FERS
Regular
Military Reserve Technicians
Special
2
Salary Offset - Reemployed
Annuitants
Military Deposit
FERS - RAE
Regular - RAE
Military Reserve Technicians - RAE
Special - RAE
3
Salary Offset - Reemployed
Annuitants - RAE
Military Deposit - RAE
Total Retirement
Grand Total
1
Employees with CPDF Retirement Codes of 1, 6, C, E, R or T.
2
Employees with CPDF Retirement Codes of L or M.
3
Employees with CPDF Retirement Codes of LR or MR.
Public Burden Statement
We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the
completed form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completing time, to the Office of
Personnel Management, Funds Management, P.O. Box 582, Washington, DC 20044. The OMB Number 3206-0262 is currently valid. OPM may not collect this
information, and you are not required to respond, unless this number is displayed.
Office of Personnel Management Standard Form 2812-A
CSRS/FERS Handbook for Personnel and Payrol
l
Offices
This form may be locally reproduced
Revised November 2013
