Form Approved OMB No. 3206-0215 Verification of Full-Time School Attendance United States Office of Personnel Management Retirement Surveys and Students Branch 1900 E St., NW Washington DC 20415-3563 Claim Number For Agency Use Only I II III Social Security Number Certification Period Date IV Student's Name Please return the completed form to us within 30 days to avoid interruption of payments for the student. The Office of Personnel Management is verifying the information you previously provided regarding the full-time attendance of the student named above. We must be sure that benefits are properly paid and continued eligibility requirements are met. Please have the verification form on the other side completed and signed by an official of the educational institution the student attended during the certification period shown above. We request that the student complete Part A and sign the release of information statement below. This will allow us to obtain any information we need from the school. Please return the completed form in the envelope provided to: Office of Personnel Management, Retirement Surveys and Students Branch, 1900 E St., NW, Washington DC 20415-3563 or fax the form to (202) 606-0022. If the student named above has attended more than one school during the requested certification period, you may duplicate the verification form for each school as necessary. Please call us at 1-888-767-6738 or (202) 606-0249 if you have any questions. PART A (To be completed by the student) 1. Did you attend more than one school during the certification period shown above? If yes, you must provide verificaton from each school. No Yes You may photocopy this form as needed. 2. Do you intend to return to school for the next school year? Yes No 3. Estimated date of return if answered yes to question 2. / m m / d d 4. Student's Phone Number ( y y y ) - y 5. I authorize the release of information about school attendance to OPM. 6. Student's Signature: 7. Date / ________________________________________ m m / d d y y y y Public Burden Statement: We think this form takes an average of 1 hour 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 (3206-0215), Washington, DC 20415-7900. The OMB Number 3206-0215 is currently valid. OPM may not collect this information and you are not required to respond unless this number is displayed. 19922 RI 25-49 Revised October 2002 American LegalNet, Inc. www.FormsWorkFlow.com For greater accuracy in processing this form, please complete the questions in a black felt tip or black ink pen. PART B (To be completed by the school) This form must be completed and signed by an authorized school official. An authorized official of a high school is the principal, vice principal, assistant principal or equivalent. Above the high school level, the form should be signed by the registrar, dean, administrator, or the equivalent. At a technical or vocational school, the president, vice president, director, or the equivalent should sign. 1. Did __________________________ attend school full-time from ________ to __________? Yes, go to item 3. No, go to item 2. 2. If the student attended school full-time for any period or periods during the school year being verified, please give the beginning and ending date for each period. First Period: / Beginning Date m m / d d / Ending Date y y y y m m / m d m d d d y y y y y y y y Second Period, if any: / Beginning Date m m / d d / Ending Date y y y y / 3. Check the type of educational institution. High School Vocational/Trade/Technical University/College/Graduate School Other 4. Name of Educational Institution 5a. Street Address 5c. State 5b. City 5d. Zip Code 6. Phone Number ( ) 7. Date - / m m / d d y y y y I certify that all information given in this verification is true and correct to the best of my knowledge and belief. OPM may further verify the information provided. 8. Signature of School Official 9. E-mail Address Privacy Act: Solicitation of this information is authorized by the Civil Service Retirement Law (Chapter 83, title 5, U.S. Code) and the Federal Employees Retirement Law (Chapter 84, 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, 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. 19922 Reverse of RI 25-49 Revised October 2002 American LegalNet, Inc. www.FormsWorkFlow.com