Request for Waiver, Extension, or Search In Connection with Election of FERS Coverage Before completing this form, read the attached Instructions for Employees and Information for Employees. Section 1. Employee Identifying Information (Type or print) Date of birth (Month, day, year) Social Security Number Name (Last, first, middle) Section 2. Addresses for OPM's Response Employee's mailing address Employing office address Section 3. Spousal Identifying Information Date of birth (Month, day, year) Former spouse's name (Last, first, middle) Section 4. A. B. Request to OPM I request that OPM determine whether it has a court order on file that awards benefits to my former spouse identified in Section 3. If a court order is on file at OPM, I request that OPM grant me a 6-month extension of time in which I can elect FERS coverage. I understand that the six-month period will run from the date my request is approved. If a court order is on file at OPM, I request that OPM waive the requirement that my former spouse consent to my election of FERS coverage based on the attached documentation. Date C. Signature of employee Notice to Agency: When OPM returns this form, see "Instructions for Employing Office" on the back of this form. Section 5. OPM's Response (To be completed by OPM) OPM does not have on file a qualifying court order awarding CSRS benefits to the employee's former spouse. Proceed with processing the employee's FERS election. OPM has on file a qualifying court order awarding CSRS benefits to the employee's former spouse. The employee may not elect FERS coverage unless (1) the former spouse consents to the election, or (2) the court order is modified to remove the award of retirement or death benefits to the former spouse. Your request for a six-month extension is approved; it expires on (date) . See attached correspondence regarding your request for a waiver of the former spouse consent requirement. Signature of OPM official Date Privacy Act Information Solicitation of this information is authorized by the Federal Employees Retirement Act (Public Law 99-335). The information you furnish will be used to identify records properly associated with your election, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a unique and 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 the civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes use of the social security number. Furnishing the Social Security Number, as well as other data, is voluntary, but failure to do so may delay or make it impossible for us to determine your eligibility to elect FERS coverage. (Formerly OPM Form 1560) Standard Form 3111 (6-90) Office of Personnel Management 5CFR 846 American LegalNet, Inc. www.FormsWorkFlow.com Information for Employees FERS is the retirement system for Federal Employees established by the Federal Employees Retirement System (FERS) Act of 1986. Employees who are covered by the Civil Service Retirement System (CSRS) may elect to transfer to FERS. If you were hired (or converted from an excluded appointment to one that is not excluded) on or after July 1, 1987, you may elect FERS coverage within 6 months after you were hired (or converted). Your current spouse doesn't have to consent to your transfer from CSRS to FERS. However, under certain conditions, you cannot transfer to FERS without the consent of a former spouse. These conditions are: You do not need the former spouse's consent if you elect to remain in CSRS. If you think you are one of the few employees whose former spouse obtained a qualifying court order that may be on file with OPM, you can ask OPM if it has a court order on file. You can also ask OPM to give you a 6-month extension of the time limit for making the election so that you can get the court order modified so that your former spouse will consent to your election or so that consent is not required (that is, by eliminating any right of your former spouse to your future retirement benefit and/or a survivor benefit). In addition, you can ask OPM to waive the requirement that your former spouse consent to your FERS election. You may use this form to request that OPM: check to see if a qualifying court order is on file; give you an extension; or waive the consent requirement. Use Standard Form 3110, "Former Spouse's Consent to FERS Election", if your former spouse consents to your FERS election. . . . . - a qualifying court order awards a portion of your CSRS annuity or CSRS survivor benefit to a former spouse; AND the court order is on file at OPM; AND the former spouse is still alive; AND the former spouse has not remarried before age 55. . . . . . . . Instructions for Employees Complete this form if you want OPM to: determine whether there is a court order on file at OPM; extend the deadline for your FERS election so you can obtain a modification of the court order; or waive the requirement that your former spouse consent to your election of FERS. Documentation required to support a request for waiver of the consent requirement. If you request that OPM waive the requirement that your former spouse consent to your election of FERS coverage, you must submit the following documentation: 1. A judicial or administrative determination that your former spouse's whereabouts cannot be determined. OR 2. Affidavits by you and two other persons, at least one of whom is not related to you, attesting to the inability to locate the former spouse and stating the efforts made to locate the spouse, AND documentary corroboration such as newspaper reports about the former spouse's disappearance. OR 3. A judicial determination regarding the former spouse that warrants waiver of the consent requirement based on exceptional circumstances. - OPM will return a copy of its response to the addresses you give in Section 2. Be sure to ask your employing office how their copy shoul