Form Approved OMB No. 3206-0099 United States Office of Personnel Management Retirement Services Program Washington, DC 20415 Initial Certification of Full-Time School Attendance Reference Date (mm/dd/yyyy) Claim number • (suffix) CSF Name of deceased employee Name of child Date of death (mm/dd/yyyy) On roll? Yes No The Application for Death Benefits shows that the child named above, a survivor of a Federal employee or annuitant, is (or soon will be) age 18. After reaching age 18, a child is eligible for a survivor annuity only if unmarried and (1) a full-time student in an accredited school or (2) incapacitated for self-support because of a physical or mental disability that began before age 18. If the child is unmarried and a full-time student, you should complete Part A on the other side of this form; a school official (the principal, administrator, registrar, etc.) should complete Part B, and you should return the completed form to us promptly. If the child's school year was not in session on the date of death (shown above), have the school official complete Part B for the last school year attended. If a child is unmarried and incapacitated for self-support because of a mental or physical disability, do not fill in the other side of this form. Instead, return the form to us with a doctor's certificate describing the nature and extent of the child's disability. After we review the documentation of the disability, we will write to you about the child's eligibility for benefits. Send the completed form to: U.S. Office of Personnel Management Retirement Services Program 1900 E Street, NW Washington, DC 20415-3563 Privacy Act Statement The Office of Personnel Management (OPM) administers the Civil Service Retirement System (Chapter 83, title 5, U.S. Code) and the Federal Employees Retirement System (Chapter 84, title 5, U.S. Code). The information requested on the enclosed form is needed to document a retirement benefit or claim. 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 from OPM, 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. Providing the information is voluntary; however, failure to supply all the requested information may delay or prevent action on the benefit or claim. Intentionally false statements and/or suspected illegal activities are reportable by us to the appropriate law enforcement agencies. Public Burden Statement We think this form takes an average 90 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 Office of Personnel Management, OPM Forms Officer (3206-0099), Washington, DC 20415-7900. The OMB Number 3206-0099 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. (THIS SPACE IS FOR THE USE OF THE OFFICE OF PERSONNEL MANAGEMENT ONLY.) Remarks: Approved Inspector Previous editions are not usable. Not Approved Because Less than full-time school attendance Not in school Over 5-month break in attendance Married Non-recognized school Other (specify) Date (mm/dd/yyyy) Call up (M-Card) processed Benefits specialist Date (mm/dd/yyyy) RI 25-41 Revised June 2006 American LegalNet, Inc. www.FormsWorkFlow.com Part A - To be completed by the payee (the person who expects to receive benefits for the student). Read the reverse side of this form before answering the questions below; give full information; typewrite or print in ink. 1. Student's name (first, middle, last) 4. Is the student married? Current Status Future Plans Payee Signs Here 2. Student's date of birth (mm/dd/yyyy) 3. Student's Social Security Number If "Yes," show the date at right, sign item 7 of this part, and return this form. (It is not necessary to complete the rest of the No form.) 5. Is the student enrolled in Yes school on a full-time basis If "No," show the date the student last at the present time? No attended school on a full-time basis. Yes 6. After the end of the school year, does the student intend to continue as a full-time student with less than a 5-month break between school years? Last attended school (mm/dd/yyyy) If "Yes," give the details in items 6a and 6b. Yes No Undecided 6a. Enter the date (or approximate date) the next school year or term begins after current enrollment (month, day, year). Date of marriage (mm/dd/yyyy) } If "No" or "Undecided," go to item 7. 6b. Complete name and mailing address (including ZIP code) of the educational institution the student will attend next year. 7. I certify that all information given in this certification is true and correct to the best of my knowledge and belief. I understand that I must immediately notify the Office of Personnel Management (OPM) if the student transfers to another school, discontinues school attendance, reduces attendance to less than full-time, marries, or dies. I further agree to return all overpayments of student benefits, including overpayments that may be erroneously made after I notify OPM of any terminating event. Signature of payee Daytime telephone number ( Date (mm/dd/yyyy) ) Part B - To be completed by an official of the educational institution for the school year to (month, year) 1. Is/was the student enrolled in and attending a full-time course of resident study or training (not correspondence) for the period requested? Yes 2. Actual date the student started school for the school year indicated above (mm/dd/yyyy) . (month, year) 3. Official ending date of the school year (mm/dd/yyyy) No 4. Check the type of educational institution: High school Vocational institute Trade school 5. Show the complete name and mailing address (including ZIP code) of the educational institution. Junior college/ community college College or university Technical institute Other (specify) 6. Show the total school hours per week: a. If college or equivalent, show credit hours b. If high school or equivalent, show actual clock hours c. If in a work-study program sponsored by the school, show hours at work hours at school Complete items 7 and 8 below if your institution is not a state college, state university, or public high school. 7. Show the complete name and address (including ZIP code) of the 8. If the educational institution is licensed, show: organization which accredits, licenses, or otherwise recognizes the school. a. Current license number: I certify that the information given in regard to requested school enrollment of the above-named student is true and correct to the best of my knowledge and belief. School Official Signature of principal, administrator, registrar, etc. Signs Here Title Telephone number ( ) Date (mm/dd/yyyy) b. Expiration date of current license (mm/dd/yyyy) Warning: Any intentionally false statement, willful concealment of material fact, or use of a writing or document knowing the same to contain a false, fictitious, or fraudulent statement or entry, 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) Reverse of RI 25-41 Revised June 2006 American LegalNet, Inc. www.FormsWorkFlow.com