UNITED STATES OFFICE OF PERSONNEL MANAGEMENT OFFICE OF RETIREMENT PROGRAMS BOYERS, PA 16017 Form Approved OMB No. 3206-0121 Date of birth Date of separation giving eligibility Commencing date of annuity YOU MAY BE ELIGIBLE FOR DEFERRED RETIREMENT Records on file with the Office of Personnel Management (OPM) indicate that you may be eligible for a deferred annuity beginning on the "commencing date" shown above. To apply for your annuity, complete the enclosed Application for Deferred Retirement and return it to OPM. See the instructions below. Your annuity will be computed under the law in effect on the date of the separation on which your eligibility for annuity is based, using your service listed below (unless we can verify additional service). If you have additional Federal service, list it in Section D of the enclosed application and send us copies of any documents you may have to support your claim to that service. A decision on your eligibility for an annuity and the amount of service to your credit will be made after we receive your application. Department or Agency and Location Beginning Date (mm/dd/yyyy) Ending Date (mm/dd/yyyy) Civil Service Retirement Deductions were: Withheld Not Withheld Refunded Remarks: Keep the instructions (pages 1 thru 8) for your files. Return this letter with your completed application in the enclosed envelope or address them to: Office of Personnel Management Retirement Operations Center P.O. Box 45 Boyers, PA 16017-0045 Prior editions are not usable. Retirement Operations Center OPM Form 1496 Revised October 2002 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR DEFERRED RETIREMENT (Separations before October 1, 1956) INTRODUCTION This package is for your use if you are a separated Federal employee who wants to apply for deferred annuity based on a separation from service covered by Civil Service Retirement law before October 1, 1956. This package does not include any information on the provisions of the Federal Employees Retirement System Act of 1986. Review all information carefully before you complete the application. Special information which applies only to certain separated Members of Congress and congressional employees has not been included. Keep the information sections of this package for future reference. If your final period of service does not meet the "one out of two" requirement, it will be eliminated from consideration. Retirement deductions withheld during the period will be refunded, and, if possible, entitlement will be based on a previous separation. INSTRUCTIONS FOR COMPLETING APPLICATION FOR DEFERRED ANNUITY Section A - Identifying Information Item 1: Item 2: Type or print your name clearly. List other names under which you have been employed in the Federal government (such as a maiden name). This will make it possible for us to locate and identify records maintained under such names. Enter the address to which correspondence should be mailed. (If you want your payments sent to a bank, do NOT enter that address here; refer to page 7 for information about how to do this.) Give a telephone number where you can be reached in case more information is needed. Give your date of birth, showing the month, then the day, then the year. Your retirement records are filed by your name and date of birth. If your date of birth is not correct on the letter with this package, send proof of your date of birth (such as your birth certificate) with your application. Enter your social security number. The Treasury Department requires us to report, by social security number, the amount paid to each annuitant. Indicate your citizenship. ELIGIBILITY FOR DEFERRED ANNUITY If you die before attaining age 62, or after age 62 but before applying for annuity, the only benefit payable will be your lump sum credit in the retirement fund; monthly survivor annuity will not be available. Deferred annuity is payable commencing the day the former Federal employee is 62, provided an application has been submitted to the Office of Personnel Management (OPM) and approved. Your "retirement date" is your 62nd birthday even if you did not apply for your annuity before you were 62. Final separation on/after January 24, 1942, but before April 1, 1948, from service covered by the Civil Service Retirement law entitles you to an annuity if: 1. You had at least 5 years of creditable civilian Federal service or a combination of creditable civilian Federal service and military service equaling 5 years, as of your final separation. 2. You have not forfeited entitlement by drawing a refund of your retirement deductions covering your final period of service. If OPM determines that your final separation during the period specified above was involuntary, not for cause, your annuity may begin at age 55. Final separation on/after April 1, 1948, but before October 1, 1956, from service covered by the Civil Service Retirement law entitles you to an annuity if: 1. You had at least 5 years of creditable civilian Federal service as of the date of your final separation. 2. You have not forfeited entitlement by drawing a refund of your retirement deductions covering your final period of service. 3. In addition, if the final separation on which your entitlement is based was on/after August 31, 1954, you must have been covered by the retirement law for at least one year out of the two-year period preceding your final separation. Item 3: Item 4: Item 5: Item 6: Item 7: Section B - Marital Information Indicate whether or not you are married now. If you are married, also complete Items 1a-1f with information about your current marriage. Information about your marital status and your spouse is necessary to assure that you get the survivor election that you want and to which you are entitled by law. Item 1a: Enter your spouse's name. Item 1b: Enter your spouse's date of birth (month-day-year). Item 1c: Furnish your spouse's social security number. Item 1d: Enter the place of your marriage (town or city and state). Item 1e: Enter the date of your marriage (month-day-year). Item 1f: If you were married by a clergyman or justice of the peace, check that box. If not, check the box marked "other" and explain how, or by whom, you were married. Item 2: Indicate whether you have a living former spouse whose marriage to you ended by divorce or annulment on or after May 7, 1985, and to whom a court order gives a survivor annuity. If you answer "yes," you must submit a certified copy of