Form Approved: OMB No. 3206-0197 United States Office of Personnel Management 1900 E Street, NW Washington, DC 20415-3564 Date Claim number CS URGENT — Reply Required Within 30 Days to Avoid Interruption of Your Payments For your protection, the Office of Retirement Programs is verifying your records to make sure the annuity payments and informational correspondence we send you are going to the right person and the correct address. If we are paying you as the survivor of a deceased Federal employee or retiree, it is your information we are verifying. The information for the deceased is already on file. Because of our responsibility to protect your annuity payments, if we do not receive your reply within thirty days, we will assume that someone else is receiving your payments. We will then suspend your payments. Please take the following actions promptly: • • • • Check the name and address shown above to be sure they are correct. Enter the information requested on the back of this letter. Place your signature in the space provided. Return this letter to the Office of Personnel Management (OPM) in the envelope we have provided. Thank you for your cooperation in this important matter. Retirement Inspection Branch Privacy Act Statement and Public Burden Statement Solicitation of this information is authorized by the Civil Service Retirement law, Federal Employees Retirement law, the Federal Employees' Group Life Insurance Program, and the Federal Employees Health Benefits Program (Chapters 83, 84, 87, and 89 of 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 uniquely 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. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a Social Security Number or tax identification number. This is an amendment to title 31, Section 7701. Failure to furnish information may delay or make it impossible for us to determine your eligibility to receive benefits. We think this form takes an average 10 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 (3206-0197), Washington, DC 20415-7900. The OMB Number 3206-0197 is currently valid. OPM may not collect this information and you are not required to respond, unless this number is displayed. Previous edition is usable. RI 38-107 Revised March 2003 American LegalNet, Inc. www.FormsWorkFlow.com Part A - Annuitant's Response (If the annuitant is deceased, go to Part B.) If the annuitant cannot sign in Item 4, complete the items as instructed but skip Item 4 and complete Item 5. Item 1 - (Check one block.) My name and correspondence address shown on the front of this notice are correct. (Complete items 2 and 4 or item 5.) My name and/or correspondence address shown on the front of this notice are not correct. (Complete items 2, 3, and 4 or item 5.) Item 2 - (Enter your identifying information.) Item 3 - (Show the correct information.) Annuity claim number Name Annuitant's Social Security Number Address Daytime telephone no. (including area code) City, State, and ZIP Code Item 4 - I certify that the above information is correct. Date (mm/dd/yyyy) Annuitant's signature (do not print) OPM will accept an "X" as your legal signature if you are unable to sign your name. If you sign with an X, we require the signatures and addresses of two witnesses who saw you make the X. Printed name of witness Printed name of witness Address Address City, State, and ZIP Code City, State, and ZIP Code Signature of witness Signature of witness Item 5 - If it is not possible for the annuitant to sign or make an X, provide the information requested below. Reason the annuitant cannot sign Relationship to the annuitant of person replying Printed name of person replying Address of person replying Daytime telephone no. of person replying (including area code) City, State, and ZIP Code Date (mm/dd/yyyy) Signature of person replying on behalf of the annuitant Part B - Deceased Annuitant (If the annuitant has died, give the following information.) Date of death (mm/dd/yyyy) Place of death Include a copy of the death certificate. Signature Date signed (mm/dd/yyyy) Your printed name and address Telephone no. (including area code) Reverse of RI 38-107 Revised March 2003 American LegalNet, Inc. www.FormsWorkFlow.com