United States Office of Personnel Management Retirement Operations Center Boyers PA 16017 Form Approved OMB No. 3206-0121 Date of birth (mm/dd/yyyy) Date of separation giving eligibility (mm/dd/yyyy) Commencing date of annuity (mm/dd/yyyy) 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 enclosed information. 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 9) 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 OPM Form 1496A Revised March 2012 American LegalNet, Inc. www.FormsWorkFlow.com Application For Deferred Retirement Civil Service Retirement System (CSRS) (Separations on or after 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 System (CSRS) on or after 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. Item 7: Item 8: Provide your email address. Indicate your citizenship. Section B - Marital Information Item 1: 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. Enter your spouse's name. Enter your spouse's date of birth (month-day-year). Furnish your spouse's Social Security Number. Enter the place of your marriage (town or city and state). Enter the date of your marriage (month-day-year). 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. 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 the court order and any attachments or amendments. Eligibility For Deferred Annuity You are eligible for a deferred annuity if: 1. You had at least 5 years of creditable civilian Federal service at the time of your final separation from a position subject to CSRS. You were covered by CSRS for at least 1 year out of the last 2 years preceding the final separation on which entitlement is based. You have not drawn a refund of retirement deductions covering your final period of service. Item 1a: Item 1b: Item 1c: Item 1d: Item 1e: Item 1f: 2. 3. 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. A deferred annuity commences on your 62nd birthday, no matter when you apply for it. 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. Item 2: Section C - Annuity Election To be eligible for a survivor annuity after your death, your widow(er) must have been married to you for a total of at least 9 months. The marriage duration requirement does not apply if your death is accidental (as defined under the retirement regulations) or your surviving spouse is a parent of your child. Box 1: Spouse Survivor Benefit If you initial either Box 1A or Box 1B, your wife or husband will receive a survivor annuity upon your death. The amount of this survivor annuity and the amount of the reduction in your annuity to provide this benefit depend on the box you initial. For a full discussion of the effect of court orders, see Important Information About Annuity Election on page 2. Box 1A: Maximum Survivor Benefit If you initial Box 1A, you are electing the maximum survivor benefit. Final Separation on or after October 11, 1962 If you initial Box 1A , your spouse's survivor annuity upon your death will be 55% of ALL of your annuity. Your annuity will be reduced by 2-1/2% of the first $3,600 and 10% of the remainder of your annual annuity to provide this benefit upon your death. 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 maiden name). This will make it possible for us to locate and identify records maintained under such names. Enter your Social Security Number. The Treasury Department requires us to report, by Social Security Number, the amount paid to each annuitant. 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 6 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