Form approved: OMB No. 3206-0167 Financial Resources Questionnaire U.S. Office of Personnel Management Retirement Services Program General Information Item 6 The purpose of this questionnaire is to determine your eligibility for: 1. waiver of the amount due the retirement system on the basis of financial hardship; 2. compromise in the amount to be repaid; 3. lower installments; and/or 4. a voluntary repayment agreement. For more information on waiver, compromise, lower installments, or voluntary repayment, please refer to our letter or notice informing you of the overpayment. (Note: If you are only requesting lower installments, you do not need to fill out this questionnaire as long as your payments will be (1) at least $50 a month and (2) sufficient to pay off the entire amount within three years.) Failure to supply all the requested information may result in an unfavorable decision. Please note that you may be asked to provide verification of the information you supply in this questionnaire (e.g., evidence of claimed expenses). To be considered for waiver, compromise, lower installments, or a voluntary repayment agreement, you must complete and return this questionnaire to us within 30 days after the date shown in the notice of overpayments. General Instructions 1. Please read all items carefully. 2. Type or print in ink. 3. Complete all items on the form. If a question does not apply, answer “No” or “None”. Do not leave it blank. If answers require additional space, continue them in Section X. Attach additional sheets if necessary. Include your name and retirement claim number in the upper right corner of each additional sheet. 4. Sign and date this questionnaire in Section XI. 5. Send the completed form to: Office of Personnel Management Attn: Funds Management P.O. Box 7125 Washington DC 20044-7125 Detailed Instructions Most of the questionnaire items are self-explanatory. Instructions are provided below for those items identified with an asterisk(*), which require further explanation. Section I - Personal Data Item 1 Give the name of the former Federal employee upon whose service your entitlement to retirement system benefits was based. (If the benefits are based upon your own service, give your name.) Section IV - Average Monthly Income Item 1 Enter your current monthly gross salary - i.e., wages, fees, commissions - for yourself and then your spouse. (Enter the total salary paid before any payroll deductions are made; e.g., Federal, state, and local taxes; social security taxes; insurance, etc.). If your salary fluctuates on a monthly basis, estimate the monthly average. Previous edition is not usable Enter all other current income not listed. This may include unemployment compensation, public assistance benefits, trust income, tax refunds, alimony, child support, royalties, payments of debts owed to you, income provided by dependents listed in Section I (other than spouse), etc. Estimate the average monthly amount. Section V - Average Monthly Expenses Item 1 Enter the amount you currently spend on average for rent, mortgage, homeowner/condominium fees, etc., each month. If you include property taxes in this item, do not include them in V.9. Item 3 Enter the average monthly amount you spend for electricity, telephone, gas, water, coal, oil, etc. Item 4 Enter the average monthly amount you spend for household maintenance (repairs, cleaning supplies, etc.) and personal necessities. Item 7 Enter the average monthly amount you spend for insurance (life, health, accident, automobile, homeowners, etc.). Do not include homeowner’s insurance if it is already included in V.1. Item 8 Transportation costs include necessary automobile expenses (gas, oil, maintenance), cab fares, and public transportation. Item 9 Enter 1/12 of all taxes you pay in a year, including Federal, state, and local taxes; property taxes not included in V.1; sales taxes not included in other items, etc. Item 10 Enter the total amount due monthly from existing liabilities as shown in Column E of Section VII. (This amount should not include any expenses - such as mortgage payments - listed under other items in Section V.) Item 11 Other living expenses which you can prove to be ordinary and necessary. Provide a breakdown of these expenses in Section X. Section VIII - Assets Item 4 Enter the cash value of your money market accounts, certificates of deposit, etc. Do not include Individual Retirement Accounts (IRA’s) or other interest bearing accounts which belong in item 6. Item 5 The current value on any stocks or bonds you own. The current value is the amount you would receive if you sold these securities. Item 6 The current value of any IRA’s, Keoughs or similar retirement savings accounts. Item 8 Identify any automobiles, vans, trucks, motorcycles, motor homes (RV’s), trailers, campers, boats, etc., that you own, and their resale value (the amount you would receive if you sold these vehicles). Any remaining liabilities for these vehicles should appear in Section VII. Item 9 The resale value of your home and other real estate. (If you own two or more properties, list separately. Also show the unpaid amount of any real estate mortgages in Section X.) Item 10 The current resale value of any other personal property (art pieces, jewelry, etc.) which can be sold and which are valued in excess of $1,000 per item. (Itemize in Section X.) RI 34-1 Revised March 2008 American LegalNet, Inc. www.FormsWorkFlow.com Financial Resources Questionnaire For Consideration in Connection With Collection of an Overpayment Please read the attached instructions and Privacy Act Statement before completing this form. Section I - Personal Data *1. Name of former Federal employee (Last, first, middle) 2. Claim number 3. Former Federal employee's date of birth (mm/dd/yyyy) 4. 5. Your date of birth (mm/dd/yyyy) 6. Your social security number 8. Your telephone number (including area code) Your name 7. Your address 9. Your dependents (list spouse first): Relationship Name (Last, first, middle) Social Security Number Date of Birth Section II -Your Current/Most Recent Employment Section III -Spouse's Current/Most Recent Employment 1. Current or most recent position (e.g., Salesclerk) 1. Current or most recent position (e.g., Salesclerk) 2. Dates of employment From (mm/yyyy) To (mm/yyyy) 3. Name and address of employer 3. Name and address of employer Section IV -Average Monthly Income Type of Income *1. Gross salary or wages (before payroll deductions) 2. Dates of employment From (mm/yyyy) To (mm/yyyy) Section V -Average Monthly Expenses Your Income $ Spouse's Income $ Type of Expense *1. Rent/mortgage payments, homeowner/condominium fees Monthly Average $ 2. Food 2. Self- employment (net) *3. Utilities *4. Household maintenance 3. Gross retirement benefits: 5. Clothing Military retired or retainer pay Social Security Payments from OPM Other (specify) 6. Medical and dental (non-reimbursable) *7. Insurance premiums *8. Transportation 4. Disability benefits (Veterans benefits, Workers' Compensation, etc.) *9. Taxes (1/12 of all yearly taxes) *10. Monthly payments on existing installment contracts and other debts (Total from Section VII) 5. Investments (interest, dividends, rental income, etc.) *6. Other (itemize in Section X) 7. Total average monthly income (add items 1 thru 6) *11. Other ordinary and necessary living expenses $ 0.00 $ 0.00 12. Total average monthly expenses (add items 1 thru 11) $ 0.00 *See "Detailed Instructions" for an explanation of this item. RI 34-1 Revised March 2008 Previous edition is not usable American LegalNet, Inc. www.FormsWorkFlow.com Section VI - Summary 1. Total Monthly Income (Section IV, line 7, combined) $ 0.00 2. Total Monthly Expenses (Section V, line 12) - 0.00 3. Balance (Subtract line 2 from line 1 above) 4. How much of the balance in item 3 can you apply toward repayment on a monthly basis? $ $ 5. If your monthly expenses exceed your monthly income, how do you pay the difference? Section VII - Installment Contracts and Other Debts Show here all debts which you are required to pay in regular monthly installments, such as car, television or appliance payments to dealers, banks, or financial companies; repayment of money borrowed for any purpose; charge accounts and credit card payments; doctor or hospital bills; taxes owed; etc. Do not include expenses (such as mortgage payments) already listed in Section V, exclusive of item 10. Note: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay in Section X. (A) Name and Address of Creditor (C) Original Amount of Debt (B) Purpose of Debt $ Total (D) Unpaid Balance (E) Amount Due Monthly $ $ 0.00 (F) Scheduled Date of Full Repayment $ $ 0.00 $ 0.00 Section VIII - Assets Type of Asset Value $ 1. Cash on hand Type of Asset Value $ *6. Individual Retirement Accounts 2. Checking account(s). Give name and address of financial institution(s) below $ $ 7. Debts owed to you (give name of debtor) $ $ 3. Savings account(s). Give name and address of financial institution(s) below *8. Vehicles Type of Vehicle Make Model Year Resale Value $ $ $ $ $ *4. Other interest-bearing account(s) *9. Resident real property & other real property owned (itemize below or in Section X) $ $ $ *5. Stocks, bonds, and other securities (itemize below or in Section X) $ $ $ $ $ *10. Other assets (itemize in Section X) 11. Total assets (total of lines 1 thru 10) $ $ *See "Detailed Instructions" for an explanation of this item. American LegalNet, Inc. www.FormsWorkFlow.com 0.00 Section IX - Additional Data If "Yes", give details in Section X. Yes No 1. Is anyone holding money or assets on your behalf? 2. Is there any likelihood that you will receive an inheritance or benefits from a trust? 3. Do you have any of the incorrectly paid checks in your possession? (If "Yes", show the total amount and return the checks immediately.) $ Section X - Remarks Use this space and additional sheets if necessary to supply any other pertinent information and to continue your answers to previous items. Indicate section and item number to which your comments apply. Section XI - Certification I affirm that the information provided herein is true, correct, and complete to the best of my knowlegde and belief. 1. Your signature 2. Date (mm/dd/yyyy) Warning Any intentionally false statement, concealment of material fact or willful misrepresentation relative to this questionnaire is punishable by a fine of not more than $10,000 or imprisonment for not more than 5 years, or both (18 U.S.C. 1001). You may be asked to furnish verification of any statement you make. Privacy Act Statement The Office of Personnel Management (OPM) administers the Civil Service Retirement System and the Federal Employees Retirement System for Federal employees as authorized by chapters 83, 84, 87, and 89 of title 5, U.S. Code, and Public Laws 83-589, 84-356, and 86-724. The Federal Claims Collection Act of 1966 as amended (Public Law 89-508) empowers the head of a Federal agency to enforce collection of claims for the United States of money or property arising out of the activities of the agency. Section 179.102 of title 5, Code of Federal Regulations, delegates authority to the Associate Director for Retirement and Insurance for collection of claims arising out of overpayment of Federal retirement benefits. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a social security number or tax identification number. This is an amendment to title 31, Section 7701. The information requested on this form is needed to evaluate your financial ability to repay OPM. The information may be shared with the General Accounting Office and the United States Department of Justice in the event litigation is required to enforce collection. This 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 civil or criminal law. Provision of the information is voluntary; however, failure to supply all requested information may result in a thorough financial investigation or a decision adverse to you. Pending the results of the investigation, evidence may be turned over to the Department of Justice for appropriate action. Intentionally false statements and/or suspected illegal activities are reportable to the appropriate law enforcement agencies. Public Burden Statement We think this form takes an average 60 minutes 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), OPM Forms Officer (3206-0167), Washington, D.C. 20415-7900. The OMB number, 3206-0167, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. American LegalNet, Inc. www.FormsWorkFlow.com