Form Approved: OMB No. 3206-0140 United States Office of Personnel Management Retirement Programs P.O. Box 45 Boyers, PA 16017-0045 Date of this letter File reference • Name of annuitant Claim number Representative Payee Application The Office of Personnel Management (OPM) has received information indicating that the above-named annuitant may not be capable of handling his or her benefits under the Civil Service Retirement System or the Federal Employees Retirement System. (Note: The annuitant may be a minor child without a parent to handle the benefits.) If the annuitant cannot handle the benefits, we require that the payments be made to a court-appointed fiduciary or to a person we select to represent the annuitant. A fiduciary is a person or institution appointed by a State court to be responsible for managing funds on behalf of another person. Under the retirement law, the preferred payee in this type of case is a court-appointed fiduciary. However, if a fiduciary has not been appointed, we have authority to make payments to a representative who is willing to act on behalf of the annuitant. In addition to receiving annuity payments, the person representing the annuitant is responsible for acting in the annuitant's best interests by using the payments to benefit the annuitant, authorizing the correct withholding of Federal income tax from the annuity, and selecting the Federally sponsored health benefits coverage for the annuitant when applicable. Payments are made to a court-appointed fiduciary or OPM-selected representative with the clear understanding that the funds will be used or conserved for the benefit of the annuitant. In the event that part or all of the annuitant's monthly payment is not required to meet his or her current needs, the representative is required to conserve the unused amount for the annuitant's future needs. The representative will be held accountable for the funds and will have to provide written reports as OPM may require to show that the payments are being properly used for the annuitant. Further, the representative is obligated to notify OPM immediately when he or she is no longer acting for the annuitant. The representative will be held liable for any payments which may be received after the annuitant dies. Such payments must be immediately returned to the U.S. Treasury Department. OPM will not make a payee change based on a power of attorney or the existence of a joint account with the annuitant at a financial institution. We require either a State court appointment of a fiduciary or an OPM-administered agreement before we will allow anyone other than the annuitant to receive payments or authorize actions based on this claim. If there is a court-appointed fiduciary, he or she may apply to become payee by sending us an original or a certified copy of the court appointment in the enclosed envelope with the attached application for selection. (Uncertified photocopies are not acceptable.) If there is no court-appointed fiduciary or if there is one, but you believe that you should receive the payments instead, please assist us in selecting a payee by completing the attached application and returning it in the enclosed envelope or to the address shown above. For more information, call the Retirement Information Office at 1-888-767-6738, Monday through Friday between 7:30 a.m. and 7:45 p.m. Eastern time or write to us at the address shown above. Thank you for your cooperation. Signature Office of Retirement Programs If this box is checked, you must submit the information described on the enclosed form along with this application. Enclosure: RI 30-3, Information Necessary for a Competency Determination Previous edition is usable American LegalNet, Inc. www.FormsWorkFlow.com RI 20-7 Revised July 2003 Application For Selection As Representative Payee of an Annuitant The Office of Personnel Management is interested in selecting the most suitable person to be the payee. It is necessary, therefore, to determine your relationship to the annuitant and the extent of your ability to take care of him or her. Please make sure that you answer all of the following questions so that we can proceed as soon as possible. Court-appointed fiduciaries must send OPM an original or a certified copy of the court appointment along with this application. (Uncertified photocopies are not acceptable.) Answer completely. Give explanations where required. Attach additional sheet if necessary. Part A - Identifying Information 1. Annuitant's claim number 2. Name of annuitant 3. Where does the annuitant live? (Street, city, state & ZIP code) 5. Your name and mailing address 6. Other names you have used 4. Your relationship to the annuitant (For example: spouse, daughter, friend) 7. Your social security number 8. Your date of birth (mm/dd/yyyy) Part B - Information About How You Will Discharge Your Duties as Payee 9. Do you live within commuting distance of the annuitant? Yes No (If "no," explain in the Remarks section how you will take care of the annuitant's financial affairs.) 10. Are you currently employed? (If "yes," show occupation here (If "no," explain in the Remarks section. For example, are you retired, unemployed, etc.?) 11. Do you have any prior experience as a representative payee? (If "yes," explain in the Remarks section.) 12. Have you ever been dismissed as a representative payee or convicted of a crime related to misuse of funds? (If "yes," explain in the Remarks section.) 13. Have you assumed the responsibility for providing care for the annuitant? (If your answer is no, show in the Remarks section the name and address of the person who has assumed this responsibility.) 14. Have you assumed the responsibility for the annuitant's routine expenses? (If your answer is no, show in the Remarks section the name and address of the person who has assumed these responsibilities.) 15. If the annuitant is not a minor, has the annuitant been adjudged incompetent by a State court? (If your answer is yes, you must attach an original or a certified copy of the court's order or decree. Uncertified photocopies are not acceptable. If the answer is no, you must attach medical documentation showing incompetence, as described on the enclosed RI 30-3.) 16. To your knowledge, has any individual been appointed, or applied for appointment, by a State court as guardian or other fiduciary charged with responsibility for the minor's or incompetent's person and/or estate? (If the answer is yes, you must provide us with that other person's name and address, in the Remarks section, and explain why you believe that it would be more in the interest of the annuitant that payment be made to you.) 17. Explain below how, if you are selected representative payee, you will use the annuity payments to meet the needs and provide for the well-being of the annuitant. If and when the annuity payments are not required to meet the current needs and provide for the well-being of the annuitant, how will you otherwise expend or conserve such monies? Complete Part C on the other side of this page. RI 20-7 Revised July 2003 American LegalNet, Inc. www.FormsWorkFlow.com Remarks Part C - Certification I certify that the above information is correct. I hereby affirm that I will comply with the following requirements if I am selected as the representative payee for the annuitant. (1) I agree to promptly notify the Office of Personnel Management in writing when I can no longer act in the best interest of the annuitant named. (2) I agree to promptly submit such written accountability reports as the Office of Personnel Management may require. (3) I agree to promptly notify the Office of Personnel Management if the annuitant or I move from the addresses I furnished in Part A. (4) I agree to promptly notify the Office of Personnel Management if the annuitant recovers the capacity to handle his or her own affairs. (5) I agree to promptly notify the Office of Personnel Management in writing if the annuitant dies and to provide a copy of the death certificate. (6) I agree to promptly notify the Office of Personnel Management if a disabled child marries or becomes self-supporting. (7) I agree that I will be liable for any payments which I receive after the annuitant's death. I understand that all such payments will be considered debts to the U.S. Government and are to be immediately returned to the U.S. Treasury Department. I further understand that failure to return such payments will result in appropriate debt collection activity, including the addition of interest and administrative charges, report to collection agencies, etc. Warning: Any intentionally false statement, willful concealment of a material fact, or use of a document knowing the same to contain false, fictitious, or fraudulent statements 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). Signature Telephone Number ( Privacy Act Statement Title 5, U.S. Code, Sections 8345 and 8466, authorize solicitation of this information to determine if you will be selected as payee for the annuitant. This 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 to determine and issue 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 the use of the Social Security Number to distinguish you from people with similar names. Provision of this information is voluntary; failure to supply all of the requested information may result in not selecting you as payee for the annuitant. Date ) Public Burden Statement We think this form takes an average of 30 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), OPM Forms Officer (3206-0140), Washington, D.C. 20415-7900. The OMB Number 3206-0140 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Reverse of RI 20-7 Revised July 2003 American LegalNet, Inc. www.FormsWorkFlow.com