Form Approved: OMB number: 3206-0235 U.S. Office of Personnel Management Civil Service Retirement System Boyers, PA 16017 Date Civil Service Claim Number CSA File Reference This is in response to your request for information on providing a survivor annuity for your former spouse. You must file a new former spouse survivor annuity election after your divorce or annulment — even if you had already elected a survivor annuity for that individual as a current spouse at the time of your retirement. The election that you made at retirement is no longer effective after your divorce or annulment. If you fail to inform OPM that your marriage ended by divorce or annulment and fail to make a new former spouse survivor annuity election after your divorce or annulment, the fact that your annuity continues to be reduced to provide a current spouse survivor annuity will not entitle your former spouse to a survivor annuity after your death. Please read the enclosed pamphlet and the information below carefully before making your election. A. Filing Time Limit: You must file your election (a) within 2 years after the date your marriage to the former spouse ended by divorce or annulment or (b) within 2 years after the date another former spouse lost entitlement to a survivor annuity benefit for which your annuity was reduced as explained in Chapter IX of the pamphlet. B. If You Elect The Maximum Survivor Benefit Available For Your Former Spouse: Your annuity will be adjusted as explained below. Please see Part IV of the pamphlet for additional information. 1. Your current gross monthly annuity rate is $__________. 2. If applicable, there will be two reductions in your annuity to provide the survivor benefit. The first reduction is $__________ for the regular cost of the survivor benefit. This reduction may stop if your former spouse loses entitlement. The second reduction represents the amount your annuity would have been reduced for the survivor benefit (plus interest) since your retirement. As of _____________________ this amount is $__________ and the monthly reduction to pay it back is $__________. This reduction is permanent; it will NOT stop if your former spouse loses entitlement. The reductions in your annuity may increase if you delay your election. 3. The above reductions to provide a survivor benefit will reduce your gross monthly annuity to $__________. 4. Your former spouse's gross monthly survivor annuity rate including all cost-of-living adjustments (COLA's) since your retirement will be $__________. Future COLA's will be applied to this rate. This is the maximum survivor benefit now available for your former spouse. C. Filing Instructions: If you want to provide the maximum available survivor benefit, please complete the election form and return it to the U.S. Office of Personnel Management, Retirement Operations Center, ATTN: PRM-STOP, P.O. Box 45, Boyers, PA 16017-0045 within the filing time limit. See Part IX of the enclosed pamphlet for information on the documents you may need to submit with your election. D. If You Want To Elect A Smaller Survivor Benefit: The reduction in your annuity will be smaller, in rough proportion to the smaller survivor benefit you elect. If you want to know the exact cost before you make your election, do not complete the election form. Instead, please specify below the monthly amount you want your former spouse to receive, provide your signature and date, and return this letter to the address shown in Part C above. We will then provide you with the information and send you another application. I request information on providing a former spouse annuity of $__________ per month. (Specify a whole dollar amount.) Signature Day time telephone number Date (mm/dd/yyyy) Signature of Administrative Legal Specialist, (724) 794-2005 Enclosures: RI 20-64A, Former Spouse Survivor Annuity Election RI 20-64B, Information on Electing a Survivor Annuity for Your Former Spouse Previous editions are not usable. American LegalNet, Inc. www.FormsWorkFlow.com RI 20-64 Revised August 2005