Form Approved: OMB No. 3206-0042 Notice of Change in Student's Status Show any address change next to your address below. U.S. Office of Personnel Management Retirement Surveys & Students Branch 1900 E Street, NW Washington, DC 20415-3563 For Agency Use Only Claim number I Date II III IV Student's name You have been receiving student survivor benefits for the student shown above based on self-certification of full-time attendance that you provided to the Office of Personnel Management (OPM) covering all or part of the current school year. This form is being sent to assist you in notifying OPM about events that effect eligibility to receive student benefits. Only return this form if the student's status has changed. This precoded form can only be used for the student shown above. If the student's status has changed, please return this form in the enclosed envelope or fax it to (202) 606-0022. If you have any questions about this form, you can call our office at (202) 606-0249. Individuals residing outside the Washington DC area can call our Retirement Information Office toll free at 1-888-767-6738. You can also write to OPM at the address shown above. If any of the events shown in number 1 apply, fill in the appropriate oval. Please write the month, day, and year that the event occurred or will occur inside the boxes provided in number 2. You should enter a leading zero for months and days with a single number, for example, March 3, 2006, would be 03/03/2006. 1. Events Reduced attendance to less than full-time Stopped school attendance (other than for regularly scheduled school breaks) Married Deceased Entered military service on active duty Entered a U.S. military academy Transferred to a non-recognized school 2. Date of Event: / Warning: / Any intentionally false or misleading statement, certification, or response you provide is a violation of the law punishable by a fine of not more than $10,000, or imprisonment of not more than 5 years, or both (18 U.S.C. 1001). I certify that all of the information given on this form is true and correct to the best of my knowledge and belief. Payee's signature Daytime telephone number Student's signature Date (mm/dd/yyyy) Previous editions are not usable RI 25-15 Revised June 2006 American LegalNet, Inc. www.FormsWorkFlow.com Information For Completing The Notice of Change In Student's Status Eligibility Information Survivor benefits can be paid to children of deceased Federal employees and retirees. The children must be between the ages of 18 and 22, unmarried, and full-time students in a recognized school. Full-time students must have a sufficient subject load to allow them to graduate within the minimum time that is considered normal for a full-time day student of the school. Generally, at a college or university, you must be enrolled for a minimum of 12 credit hours per semester to be considered a full-time student. If you carry fewer than 12 credit hours at any time during the school year but believe that school attendance was full-time, please send us a letter from the school stating whether the school considers it full-time. A recognized school is a non-correspondence institution of learning, high school, or above, that has a faculty and requires that study or training be accomplished on its premises. Included are high schools that are licensed by the state, and trade schools, colleges, and universities that are accredited by nationally recognized accrediting agencies. Not included as "recognized" for purposes of receiving student benefits are: elementary schools, correspondence schools, U.S. Military Academies, such as the U.S. Naval Academy, or any training program where a trainee receives pay primarily as an employee (e.g., an apprenticeship training program). Benefits (payments) must stop if the student: 1. reduces school attendance to less than full-time, 2. stops school attendance, 3. marries, 4. dies, 5. enters military service on active duty, 6. enters any of the U.S. military academies, or 7. transfers to a non-recognized school. Students who attain age 22 during the school year (between September 1 and June 30) may receive benefits through the end of the month preceding the month in which full-time schooling stops or June 30, whichever occurs first. Notify OPM immediately if any of these events occurs. If you are paid benefits after any of these events, you have been overpaid and we will have to recover the money from you. Privacy Act Statement Solicitation of this information is authorized by the Civil Service Retirement System (Chapter 83, title 5 U.S. Code), and the Federal Employees Retirement System (Chapter 84, title 5, U.S. Code). The information requested on this form is needed to support an annuity benefit or claim. The information may be shared and is subject to verification via paper, electronic media, or through use of computer matching programs, with national, state, local, or other charitable or social security administrative agencies. This may occur in order to determine benefits under their programs, to obtain information necessary for determination or continuation of benefits from OPM, 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 this information is voluntary; however, failure to furnish the requested information may result in an overpayment of annuity. We will have to collect any overpayment of annuity. Public Burden Statement We think providing this information takes an average 20 minutes per response, including the time for reviewing instructions, getting the needed data, and reviewing the requested information. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the U.S. Office of Personnel Management, OPM Forms Officer, (3206-0042), Washington, DC 20415-7900. The OMB Number, 3206-0042, is currently valid. OPM may not collect this information, and you are not required to respond, unless the number is displayed. Reverse of RI 25-15 Revised June 2006 American LegalNet, Inc. www.FormsWorkFlow.com