Form approved: OMB number 3206-0187 United States Office of Personnel Management Check Loss PO Box 7815 Washington, DC 20044-7815 • We Need More Information About Your Missing Payment We are sending you this letter because of the inquiry you made by phone. Your correspondence is being returned because we need additional information before we can help you. We attempted contacting you by telephone. However, we were unsuccessful. You may use the other side of this form to report that you have not received a payment authorized by the retirement system, because the payment was lost, stolen, destroyed, or (if a direct deposit) it was not properly credited to your account at a financial organization. If you wish to file a report of nonreceipt of payment, please complete the other side of this form. Remember to sign it and return it without delay to the address shown at the top of this page. The Office of Personnel Management (OPM) will send your report to the Department of the Treasury, which maintains all records on issued payments, so that corrective action may be taken on your behalf. No action can be taken on your report unless you return this form with the other side properly completed. The retirement system will send your report to the Department of the Treasury as quickly as possible after receipt of the completed form. If your payment was a check, the Department of the Treasury will determine whether it has been cashed. If it has not been cashed, a replacement check will be sent to you. If it has been cashed, the Department of the Treasury will contact you with further instructions. If your payment was by direct deposit, you will need your financial organization's assistance in filling out the report on the other side of this form. You must complete Parts A and B and sign the certification. Your financial organization must complete Part C at the bottom of the form and sign the Financial Organization's Certification in order for action to be taken on the report. The Treasury will trace the payment and contact you with further instructions. You must return this notice to us. We cannot take any action until you complete the form on the reverse of this notice and return the information to us. If you need assistance in completing this form, telephone OPM's Retirement Information Office at 1-888-767-6738. Customers within local calling distance to Washington, DC must contact us on 202-606-0500. Our hours are 7:30 a.m. to 7:45 p.m. Eastern Time. Signature Title Office of Retirement Programs Reports of lost or stolen checks outnumber reports about not receiving direct deposits by one hundred to one. Get direct deposit -- know your payments are safe and sure. Privacy Act Statement Public Burden Statement Title 5, U.S. Code, Chapter 83, Civil Service Retirement and Chapter 84, Federal Employees Retirement System authorize solicitation of this information. The data you furnish will be used to submit a claim for your missing payment. 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 to determine and issue benefits under their programs 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. 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. Failure to furnish the requested information may result in OPM being unable to assist you. We think this form usually takes 10 minutes per response to complete; on occasion it may take up to 30 minutes, 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, Reports and Forms Coordinator (3206-0187), Washington, DC 20415-7900. The OMB number, 3206-0187 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. RI 38-31 Revised April 2001 Previous editions are not usable. American LegalNet, Inc. www.FormsWorkFlow.com A. Payee Information and Statement The retirement payment described below has not been received or has been lost. If the address to the left should be changed and you have not notified the Office of Personnel Management, write your correct address below. Name of person to whom payment was sent Name Street address, including apt. no. to which check was sent Street address, including apt. no. City State The missing payment is ZIP Code City State ZIP Code A direct deposit to a financial organization Have your financial organization verify nonreceipt by completing Part C below. A check Did you receive the missing check? Did you sign your name on the check before it was missing? Yes Yes No No B. Description of the Missing Payment - Answer question 1 below and follow the instructions beside the block you check. 1. The missing payment is (check one block). Annuity/alternative annuity (Answer questions 2, 3, and 4 below.) Death benefit lump sum payment (Answer questions 2, 3, 4, 5, 6, and 7 below.) Survivor annuity (Answer questions 2, 3, 4, and 5 below.) Refund of retirement deductions (Answer questions 3, 4, 8, and 9 below.) 2. Claim number (CSA is an annuity claim; CSF is a survivor annuity or a death benefit lump sum payment claim. Enter your claim number in the box that applies to you.) CSA CSF 3. Approximate date of payment (mm/dd/yyyy) 4. Amount of payment $ 5. Full name of the deceased former employee (last, first, middle) 6. Former employee's Social Security Number 7. Former employee's date of birth (mm/dd/yyyy) 8. Your Social Security Number 9. Your date of birth (mm/dd/yyyy) Please review the above responses to be sure you have provided all the information requested on the line you checked in item 1. Warning: If, after you receive a replacement payment as a result of this claim, we determine that you cashed or received the benefit of both the original and any replacement payments, we will take prompt action to recover the amount of the overpayment from you. Certification - I certify that the payment described was not received or was received and is missing. Signature Telephone number (include area code) Date (mm/dd/yyyy) C. Description of Direct Deposit - If your payment is being deposited directly to a financial organization, your financial organization must complete this part. Financial organization routing number Depositor account number Type of account (check one) Checking Savings Financial organization's Certification - I certify that the payment described was not received by this financial organization. Signature of authorized financial organization officer Date (mm/dd/yyyy) Financial organization name and address Reverse of RI 38-31 Revised April 2001 American LegalNet, Inc. www.FormsWorkFlow.com