United States Office of Personnel Management Request for Offset for Health Benefits Premiums From Monies Payable Under the Civil Service Retirement System (CSRS) or the Federal Employees Retirement System (FERS) (In Lieu of Standard Form 2805) Office of Personnel Management Retirement Operations Center Boyers, PA 16017 The former employee named below is indebted to the United States (under § 890.502(b) of title 5, Code of Federal Regulations) for health benefits premiums. To liquidate this indebtedness, we request that you set off the gross amount of the debt as shown below, against the former employee's account in the Civil Service Retirement and Disability Fund. The former employee's retirement record (Standard Form 2806 or Standard Form 3100) is is not attached. Name of office designated by the employing agency to receive evidence of the liquidation of the debt. Street address City, state, and ZIP code Retirement system Name of former employee FERS Date of birth Each period of non-pay status for which offset is required From To Date of termination of service CSRS Social Security Number Amount of debt for each period Total amount of debt $ 0.00 Location of employment (city, state) Payroll office number Appropriation or fund (title and symbol number) Disbursing office (name and symbol number) I certify that this debt is properly due the United States, and that before making this request, we notified this individual that OPM will make the collection from any CSRS or FERS benefits payable. A copy of the former employee's signed consent is attached. Signature of certifying official Name of certifying official (typed or printed) Date Title of certifying official (typed or printed) Telephone number (including area code) American LegalNet, Inc. www.FormsWorkFlow.com OPM 1522 Revised June 2006 Previous edition is not usable.