Form approved: OMB No.: 3206-0245 Claim number CSA U.S. Office of Personnel Management Retirement Services and Management Group P.O. Box 45 Boyers, PA 16017-0045 Attention: Y-Adjustment Request for Change to Unreduced Annuity In order to change my benefit to the unreduced annuity rate, I am providing the information below. The reason my marriage ended is: Spouse Died Divorce Annulment The date my marriage ended is: I have enclosed: (Check one block below.) A copy of the death certificate. A court-certified copy of my divorce decree, including all property settlements. A court-certified copy of my annulment. I understand that if I have self and family health benefits coverage, I can change to self-only at any time. Change my coverage to self-only. (Note: Check this block if you want to make the change. A former spouse is no longer a family member and is not eligible for coverage under your family enrollment.) Signature (do not print) Date Name (last, first, middle initial) Telephone number including area code ( ) Public Burden Statement We think this form takes an average of 30 minutes per response to complete. 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 Forms Officer (3206-0245), Washington, D.C. 20415-7900. The OMB number 3206-0245 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Previous editions are not usable. RI 20-120 Revised September 2006 American LegalNet, Inc. www.FormsWorkFlow.com