Application for Immediate Retirement Federal Employees Retirement System Federal Employees Retirement System This application is for you if you are a Federal employee covered by the Federal Employees Retirement System (FERS) and you wish to apply for retirement with an immediate annuity. You should use this application if you want to apply for an annuity which will begin within 30 days of your separation from Federal service. Do not use this application to apply for a deferred annuity. A deferred annuity begins more than 30 days after the date of final separation. If you want to apply for a deferred annuity, call the Office of Personnel Management (OPM) on 1-888-767-6738 (TTY: 1-855-887-4957) to request an RI 92-19, FERS Application for Deferred or Postponed Retirement. If you prefer, you can write to us at Office of Personnel Management, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045, or email us at retire@opm.gov. You can also find this form on our website at www.opm.gov/forms. You should have received an informational pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System, with this application. If you did not receive the pamphlet you should get a copy from your employing agency or from our website at www.opm.gov. Retirement benefits and retirement processing are complicated. Read the information in the pamphlet carefully. When you decide to retire, give your agency advance notice so it can be sure your records are complete and it can carry out its responsibilities in processing the paperwork associated with your retirement. Give your completed application to the personnel office of your employing agency. They will forward your application to your agency payroll office and then to the Office of Personnel Management for processing. If you have any questions, ask your employing office for assistance. You must apply separately for any benefits payable from the Thrift Savings Plan and the Social Security Administration. If your address changes after your application has been forwarded to the Office of Personnel Management, call us on 1-888-767-6738 (TTY: 1-855-887-4957). If you prefer, you can write to us at the address above. If you have received your claim number, please refer to it. If you have not received your claim number we'll need your name, date of birth and social security number. Instructions for Completing Application Type or print clearly. If you need more space in any section, use a plain piece of paper with your name, date of birth, and Social Security Number written at the top. If you do not know an answer write "unknown." If you are unsure of information (for example, if you do not know an exact date), answer to the best of your ability, followed by a question mark (?). The following additional information should help you to answer those questions on the application which are not entirely self-explanatory. Section A - Identifying Information Item 2: List other names under which you have been employed in the Federal government (such as a maiden name). This will help us to locate and identify records maintained under these names. Item 3: Enter the address to which correspondence should be mailed. Do not enter the bank address where your payments will be deposited here; see Section H of the application form for payment information. Item 4: Indicate whether or not you have performed active duty that terminated under honorable conditions in the armed services or other uniformed services of the United States including the following: a. Army, Navy, Marine Corps, Air Force or Coast Guard of United States; b. Regular Corps or Reserved Corps of the Public Health Service after June 30, 1960; c. Commissioned Officer of the National Oceanic and Atmospheric Administration after June 30, 1961 or a predecessor entity in function ; d. Cadet at the U.S. Military Academy, U.S. Air Force Academy, U.S. Coast Guard Academy, or midshipman at the U.S. Naval Academy. e. Excluding the National Guard, active service in the reserve components of the uniformed services, including active duty for training, is military service. Service as a National Guard member does not meet the definition of military service for purposes of civil service retirement, except when the member is ordered to active duty in the service of the United States or performs full-time National Guard duty (as such term is defined in section 101(d) of title 10) if the National Guard duty interrupts creditable civilian service under subchapter I of chapter 84 of title 5, and is followed by reemployment in accordance with chapter 43 of title 38 that occurs on or after August 1, 1990. Item 4: Give a telephone number where you can be reached after you retire and the best time to reach you during business hours. Section B - Federal Service Item 2: Enter the date of final separation for retirement. (Leave blank if applying for disability retirement and not separated.) Please note that if you are currently serving in more than one appointive or elective position in the Federal Government, you must separate from all such positions before you can qualify for an immediate retirement. CSRS/FERS Handbook for Personnel and Payroll Offices 3107-107 Previous editions are not usable. Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com If you have performed such service, complete and attach Schedule A, furnishing the requested information for each period of active duty. a disability incurred in combat with an enemy of the United States; or caused by an instrumentality of war in the line of duty during a period of war as defined by Section 1101 of title 38. To receive FERS credit for military service performed on or after January 1, 1957, you must pay a deposit. The amount of the deposit is: Attach a copy of your retirement order from your military service to this application. If applicable, also attach a copy of your military service's determination that your military disability retirement was service connected and incurred in combat as described, or caused by an instrumentality of war as described. Only your military service branch can make this determination; the Department of Veterans Affairs cannot make this determination. If you do not have verification of the type and conditions of your military retirement, you should get the verification from the retirement service organization of your military service before you retire from your civilian position. If you are waiving military retired pay for FERS retirement purposes, your agency can help you prepare your request for waiver. Attaching a copy of your waiver request and the military finance center's acknowledgment (if available) to your application may help us to process your claim more quickly. (Even if you have already waived your military retired pay to receive benefits from the Department of Veterans Affairs, you also need to file a waiver for FERS.) Obtain counseling from the military before waiving military retired pay for FERS retirement if you receive or may receive Combat Related Special Compensation (CRSC) or concurrent receipt of military retired pay and veterans compensation. Reminder: Even if you have waived military retired pay or qualify for one of the exceptions to waiver, you must pay a military deposit for your military service performed after 1956 to receive credit for the service in your FERS annuity, and the military deposit must be paid to your employing agency before you retire. For service performed through 12/31/98 (3% of your military basic pay). For service performed from 1/1/99 through 12/31/99 (3.25% of your military basic pay). For service performed from 1/1/00 through 12/31/00 (3.4% of your military basic pay). For service performed from 1/1/01 to the present (3% of your military basic pay). You must pay the deposit to your agency while you are still employed. You may not pay OPM after you retire. If you are entitled to have part of your retirement computed under CSRS rules, military service performed prior to your transfer to FERS comes under CSRS deposit rules. These rules are as follows: The CSRS deposit is 7 percent of your military basic pay. If you were first employed in a civilian position subject to CSRS coverage before October 1, 1982, you do not pay the deposit and you are eligible for a Social Security benefit at age 62, the CSRS part of your annuity will be recomputed at age 62 to delete credit for the post-1956 military service. If you were first employed in a civilian position subject to CSRS coverage on or after October 1, 1982, you will not receive any credit for post-1956 military service if you do not make the deposit for it. Section C - Marital Information Item 2: Indicate whether you have a living former spouse to whom a court order awards a survivor annuity or a portion of your retirement benefits based on your Federal employment. If you answer "yes," you must submit a certified copy of the court order and any attachments or amendments. CSRS military service deposits must also be paid to your agency while you are still employed. The law gives an alternate method to compute the military deposit if an employee served on active duty, and such service interrupted creditable civilian service under subchapter I of chapter 84 of title 5, and was followed by reemployment in accordance with chapter 43 of title 38 that occurs on or after August 1, 1990. The employee pays no more than the amount of retirement contributions that would have been withheld from basic pay during civilian service if the employee had not performed the period of military service. Section D - Annuity Election (See pages 13-20 of SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System.) Read the information about survivor benefits found in the pamphlet, Applying for Immediate Retirement Under FERS, before completing Section D. Item 5: If you are receiving, or have applied for, military retired pay or benefits from the Department of Veterans Affairs in lieu of military retired pay, answer "yes" to Item 5, then complete and attach Schedule B-Military Retired Pay. (Note: Military retired pay includes disability retired pay and reserve retainer pay.) Survivor elections terminate upon the death of the person elected. An election of a survivor annuity for a current spouse in box 1 or 2 also terminates upon a divorce from that spouse. An election of a survivor annuity for a former spouse in box 5 also terminates if that former spouse remarries before age 55, unless the annuitant and the former spouse were married for 30 years or more. You must notify us when one of those events terminating a survivor election occurs. Also notify us if a former spouse who is entitled to a survivor annuity under a court order acceptable for processing becomes ineligible for the former spouse annuity because of a reason specified in the court order or because of a remarriage prior to age 55. This information is needed to assure correct credit for military service. With limited exceptions, you must waive your military retired pay to receive credit for your military service in your FERS annuity. You may receive credit in your FERS annuity for your military service without waiving your military retired pay if you are entitled to military retired pay awarded for: reserve service under Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10); or 2 Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Please note that, in accordance with the law, both a survivor annuity election made at retirement and a survivor annuity election made before a divorce, terminate upon death or divorce and the annuitant must make a new election (reelection) within 2 years after the terminating event to provide a survivor annuity for a spouse acquired after retirement or for a former spouse. Continuing a survivor reduction, by itself, is not effective to reelect a survivor annuity for a spouse married after retirement or for a former spouse. Box 4: If you initial Box 4, a person selected by you, who has an insurable interest in you, will receive a survivor annuity upon your death. Insurable interest exists if the person named may reasonably expect to derive financial benefit from your continued life. A disabled child or a former spouse are persons who might have an insurable interest in you. You may elect to provide a survivor annuity for more than one former spouse. The total of the survivor annuities must equal either 25% or 50% of your unreduced annuity. If you are married, you must have your spouse's consent to choose this option, because any benefit elected for a former spouse limits what can be elected for your current spouse. (Complete and attach SF 3107-2, Spouse's Consent to Survivor Election, to your application.) The maximum combined survivor benefits that can be elected for your current and former spouse(s) is 50% of your benefit. Section E - Insurance Information Item 1b: Indicate whether there is a court order or administrative order currently in effect that requires you to provide health benefits coverage for your child(ren). If you answer "yes", you must submit a copy of the court order or administrative order. If you choose an insurable interest survivor annuity, the survivor annuity will be 55 percent of your annuity after your annuity has been reduced to provide this benefit. The table below shows the reduction percentages. Any employee who is not retiring for disability and who can prove good health may elect a reduced annuity to provide a survivor annuity for a person having an insurable interest in the retiree. Section F - Other Claim Information Item 1: If you have applied for, or have ever received, workers' compensation from the Office of Workers' Compensation Programs, U.S. Department of Labor, because of a job-related illness or injury, check the "yes" box and complete Schedule C. You may elect this insurable interest survivor annuity in addition to a regular survivor annuity for a current or former spouse. If you elect an insurable interest annuity for your current spouse, you must both jointly waive the current spouse annuity. Generally, an insurable interest annuity cannot be cancelled. However, if you elect an insurable interest annuity for your current spouse because a former spouse is entitled to the regular survivor annuity (under a court order acceptable for processing or based on your election of that survivor benefit for the former spouse), you can convert the insurable interest election for your current spouse to a current spouse annuity within two (2) years of the former spouse losing entitlement to the regular survivor annuity. In Schedule C you should provide the following information: 1. 2. Age of the Person Named in Relation to That of Retiring Employee Reduction in Annuity of Retiring Employee Older, same age, or less than 5 years younger 10% 5 but less than 10 years younger 15% 10 but less than 15 years younger 20% 15 but less than 20 years younger 25% 20 but less than 25 years younger 35% 30 or more years younger 40% Indicate whether you agree to notify us if the status of your workers' compensation claim changes and whether or not you authorize the Office of Personnel Management and/or the Office of Workers' Compensation Programs to collect any overpayment if we find that you were paid, but not eligible for, both compensation and annuity benefits covering the same period of time. Without this authorization from you, we will not pay your annuity until we can confirm that OWCP is not paying you compensation. 30% 25 but less than 30 years younger If you have applied for, but are not receiving benefits, indicate whether your claim is pending or has been denied and the claim numbers applicable. 3. If you choose an insurable interest annuity, the amount of the reduction in your annuity will depend upon the difference between your age and the age of the person named as survivor annuitant, as shown in the table below. If you are receiving or have received compensation, enter your compensation claim number(s), the beginning and ending dates of each period for which compensation was paid, and whether the benefits were a scheduled award, disability or other type of compensation. Box 5: If you initial box 5, your former spouse(s) will receive a survivor annuity upon your death. The maximum survivor annuity payable to your former spouse(s) is 50% of your unreduced annuity. Your annuity will be reduced 5% or 10% according to the total benefit you want to provide. The information requested regarding benefits from the Office of Workers' Compensation Programs is needed because the law prohibits the dual compensation which would exist if you received both a FERS annuity and compensation for total or partial disability under the Federal Employees' Compensation Act. Section G - Information About Children Complete Section G by providing the names and dates of birth of your unmarried dependent children under the age of 22. Also list any child who is over age 22 and incapable of self-support because of mental or physical disability incurred before age 18. Check the box headed "disabled" by the name of each child to whom this applies. Information about your children in your annuity claim file may help to expedite the processing of claims for survivor benefits in the event of your death. 3 Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com You cannot receive your annuity payments by direct deposit or the Direct Express debit card program if your permanent payment address is outside the United States in a country where these programs are not available. Section H - Payment Instructions Complete in all cases. The US Department of the Treasury pays all Federal benefit payments electronically. Most Federal payments are paid by Direct Deposit into a savings or checking account at a financial institution. If you do not have a bank account, or prefer not to have your annuity payments deposited directly to your bank account, you can choose a Direct Express debit card. If you choose this option, your annuity payment will be automatically deposited to the Direct Express card on the payment date. To obtain a debit card, go to www.godirect.org or call 1-800-333-1795. If your payments are not electronically deposited to your account and you do not have a Direct Express card, you must contact the Department of the Treasury at 1-800-333-1795. Section I - Applicant's Certification Be sure to sign (do not print) and date your application after reviewing the warning. Privacy Act Statement Solicitation of this information is authorized by the Federal Employees Retirement law, (Chapter 84, title 5, U.S. Code), the Federal Employees Group Life Insurance law (Chapter 87, title 5, U.S. Code) and the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a unique identifiable claim file. The 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. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number. The Government may use your number in collecting and reporting amounts that you owe the Government. Failure to furnish the requested information may delay or prevent action on your application. Information you provide about your unmarried dependent children may be used to expedite their claims after you die; however, your failure to supply such information will not affect any future rights they may have to benefits. 4 Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com See Privacy Act Information on Instruction Sheet Application for Immediate Retirement Federal Employees Retirement System Federal Employees Retirement System Section A - Identifying Information 1. Name (last, first, middle) 3. Address (number, street, city, state, ZIP code) 2. List all other names you have used 4a. Daytime telephone # after retirement (including area code) 4b. Best time to reach you 4c. Email address 4d. FAX Number 5. 7. Are you a citizen of the United States of America? Yes Date of birth (mm/dd/yyyy) 8. Is this an application for disability retirement? 6. Social Security Number Yes (Ask your employing office about other documents you must submit) No No Section B - Federal Service Department or agency from which you are retiring (include bureau or division, address and ZIP code) 2. Date of final separation (mm/dd/yyyy) 3. 1. Title of position from which you are retiring 3a. Your pay plan and occupational series 4. Have you performed active honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definitions)? 5. Are you receiving or have you applied for military retired pay? (Note: If you later become entitled to military retired pay you must notify OPM.) Yes (Complete Schedule A and attach it to this form) No Yes (Complete Schedule B and attach it to this form) No Section C - Marital Information (All applicants must complete questions 1 and 2 below.) 1. Are you married now? (A marriage exists until ended by death, divorce, or annulment.) Yes (Complete items 1a - 1f and attach a copy of your marriage certificate) 1a. Spouse's name (last, first, middle) 1d. Place of marriage (city, state) 2. 1b. 1e. Date of marriage (mm/dd/yyyy) Spouse's date of birth (mm/dd/yyyy) 1f. Marriage performed by: No (Go to item 2) 1c. Spouse's Social Security Number Clergyman or Justice of Peace Other (explain): Do you have a living former spouse(s) to whom a court order gives a survivor annuity or a portion of your retirement benefits based on your Federal employment? Yes (Attach a certified copy of the court order[s] and any amendments.) No Section D - Annuity Election Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested. Read the pamphlet SF 3113, Applying for Immediate Retirement under FERS and the explanations below and consider your election carefully. No change will be permitted after your annuity is granted except as explained in the pamphlet. If you are married at retirement, the law provides an annuity with full survivor benefits for your spouse unless your spouse consents to your election not to provide maximum survivor benefits. Your election to provide a survivor annuity for a current spouse terminates upon the death of that spouse or if the marriage ends due to divorce or annulment. You are required to make a new election (reelect) within 2 years of the terminating event if you wish to reelect a survivor annuity for a former spouse or within 2 years of a post-retirement marriage to elect a survivor annuity for a spouse acquired after retirement. Continuing a survivor reduction by itself, is not effective to reelect a survivor annuity for a spouse married after retirement or for a former spouse. If you want to elect a partial survivor annuity for your current spouse and a survivor benefit for a former spouse, you should complete options 2 and 5 below. The total of the survivor annuities elected cannot exceed 50 percent. An election of an insurable interest survivor in option 4 is not included when determining the 50 percent maximum. 1. I choose a reduced annuity with maximum survivor annuity for my spouse named in Section C. If you are married at retirement, Initials you will receive this type of annuity unless your spouse consents to your election not to provide maximum survivor benefits. If you receive this annuity, your annuity will be reduced by 10%. Your spouse's annuity upon your death will be 50% of your unreduced earned annuity. 2. I choose a reduced annuity with a partial survivor annuity for my spouse named in Section C. If you choose this option, your Initials annuity will be reduced by 5%. Upon your death, your spouse's annuity will be 25% of your unreduced earned annuity. You must have your spouse's consent to choose this option. Complete form SF 3107-2, Spouse's Consent to Survivor Election, and attach it to your application. 3. I choose an annuity payable only during my lifetime. If you are married at retirement, you cannot choose this type of annuity Initials without your spouse's consent. No survivor annuity will be paid to your spouse after your death if he or she consents to this election and any health benefits will cease. In addition, your spouse will not be eligible to enroll in the Federal Long Term Care Insurance Program, if he/she is not enrolled at the time of your death. If you are married and elect this, complete form SF 3107-2, Spouse's Consent to Survivor Election, and attach it to your application. CSRS/FERS Handbook for Personnel and Payroll Offices 3107-107 Previous editions are not usable. Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com 4. Initials I choose a reduced annuity with survivor annuity for the person named below who has an insurable interest in me. You must be healthy and willing to provide medical evidence if you choose this type of annuity. (Disability annuitants are not eligible to choose this type of annuity.) If you are married and elect this option for your spouse, complete SF 3107-2, Spouse's Consent to Survivor Election and attach it to your application. Name of person with insurable interest 5. Initials Date of birth (mm/dd/yyyy) Relationship to you Social Security Number I choose a reduced annuity with survivor annuity for my former spouse(s) as follows: You must attach: (1) Copies of divorce decrees for all former spouses for whom you elect to provide a survivor annuity. (2) If you are married, attach a completed SF 3107-2, Spouse's Consent to Survivor Election. You cannot choose this option and provide a maximum survivor annuity for your spouse (Box 1). Your election to provide a survivor annuity for a former spouse terminates upon the death of that spouse or the remarriage of your former spouse before age 55. Name and address of former spouse Date of marriage (mm/dd/yyyy) Survivor annuity equal Date of birth (mm/dd/yyyy) Social Security Number to _______________% Date of marriage (mm/dd/yyyy) Date of divorce (mm/dd/yyyy) Survivor annuity equal Date of birth (mm/dd/yyyy) Name and address of former spouse Date of divorce (mm/dd/yyyy) Social Security Number to _______________% of my annuity of my annuity Total (either 25% or 50% of your unreduced annuity)  _______________% See the pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System, for information. 1a. Are you eligible to continue Federal Employees Health Benefits coverage as a 1b. Is there a court order or administrative order currently in effect that requires retiree? you to provide health benefits coverage for your child(ren)? Section E - Insurance Information Yes Yes (Attach a copy of the court/administrative order) No 2. 3. No Are you eligible to continue Federal Employee's Group Life Insurance coverage as a retiree? Are you enrolled in the Federal Dental and Vision Insurance Program (FEDVIP)? Yes No Yes  Your coverage will automatically continue into retirement as long as you continue to pay applicable premiums. Until work on your annuity is completed, you may receive bills from BENEFEDS. You must pay these bills in order to keep your FEDVIP coverage. After work on your annuity is completed, BENEFEDS will automatically begin deducting from your annuity to pay future premiums. If you have questions, please contact BENEFEDS at 1-877-888-3337. No  If you retire on an immediate annuity, you can enroll in FEDVIP during any Federal Benefits Open Season. 4. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)? Yes  You will automatically continue your coverage into retirement, as long as you continue to pay applicable premiums. If you are currently paying FLTCIP premiums by agency payroll deduction, you must arrange to pay premiums another way, either by deductions from your annuity, through automatic bank debit or direct bill. Please call LTC Partners at 1-800-LTC-FEDS (1-800-582-3337) to make these arrangements. No Section F - Other Claim Information 1. Have you applied for, are you receiving, or have you ever received workers' compensation from the Department of Labor because of a job-related illness or injury? 2. Have you previously filed any application under the Civil Service Retirement System or Federal Employees Retirement System (for retirement, refund, deposit or redeposit, or voluntary contributions)? Yes (Complete Schedule C and attach it to this form) No Yes (Complete items 2a and 2b below.) 2a. Type of application Retirement Refund Return of excess deductions No Deposit or redeposit Voluntary contributions 2b. Claim number(s) Section G (Optional) - Information About Your Unmarried Dependent Children 1. Dependent child's name (first, middle, last) CSRS/FERS Handbook for Personnel and Payroll Offices 2. Date of birth (mm/dd/yyyy) 3. Disabled 1. () 3107-107 Previous editions are not usable. Dependent child's name (first, middle, last) 2. Date of birth (mm/dd/yyyy) 3. Disabled () Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Section H - Payment Instructions 1. Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department of the Treasury. See the instructions for Section H of this application and SF 3113 (Applying for Immediate Retirement Under the Federal Employees Retirement System) for additional information. This does not apply to you if your permanent payment address is outside the United States in a country not accessible via direct deposit. Please select one of the following: Please send my annuity payments directly to my checking or savings account. (Go to item 2) Please send my annuity payments to my Direct Express debit card. (Go to item 3a) My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to item 3a) 2a. Financial Institution Routing Number 2b. Checking or Savings Account Number You may obtain this number by calling your bank, credit union, or savings institution. This number is very important. We cannot pay by direct deposit without it. 2c. What kind of account is this? Checking Savings 2e. Name and address of financial institution 3a. Do you want Federal income tax withheld from your annuity payments? Yes (Go to item 3b) 2d. Telephone number of your Financial Institution (including area code) Special Note: If you prefer, you may attach a cancelled personal check that shows the information requested above, instead of filling in the requested financial institution information. If you attach your personal check, it is especially important that you contact your bank, credit union, or savings institution to confirm that the information on the check is the correct information for direct deposit. (Some institutions, especially credit unions, use different routing numbers on checks.) We can then use this information to start paying you by direct deposit. 3b. Do you want to have Federal Income Tax withheld at the rate currently being withheld from your salary? Yes (Attach copy of W-4 form on file with your employing agency.) No (Attach new W-4 form, otherwise withholding will be at rate for married with 3 exemptions.) No (Go to Section I) Section I - Applicant's Certification Warning I hereby certify that all statements made in this application are true to the best of my knowledge and belief. Any intentionally false statement in this application or willful misrepresentation relative Date (mm/dd/yyyy) thereto is a violation of the law punishable by a Signature (Do not print) fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001) Applicant's Checklist This checklist is provided to help you be certain you have attached all necessary documentation and to help your employing office be certain it forwards all of your retirement documentation to the Office of Personnel Management. 1. No Not Applicable Military Service - If you answered "yes" to Section B, Item 4, did you attach Schedule A? 2. Yes Military Service - If you completed Schedule A, did you attach a copy of your discharge certificate or other certificate of active military service? 3. Military Retired Pay - If you answered "yes" to Section B, Item 5, did you attach Schedule B? 4. Military Retired Pay - If you completed Schedule B and answered "yes" to Item b or c, did you attach a copy of the notice of award or other documentation of the type of military retired pay you are receiving? 5. Military Retired Pay - If you completed Schedule B and answered "yes" to item d, did you attach a copy of your request for waiver and a copy of the military finance office's acknowledgment or approval of your request for waiver (if applicable)? 6. Survivor Election - If you are married and did not initial box 1 of Section D, did you attach SF 3107-2, Spouse's Consent to Survivor Election? 7. Life Insurance - If you answered "yes" to Section E, item 2, did you attach SF 2818, Continuation of Life Insurance Coverage As an Annuitant or Compensationer? 8. OWCP - If you answered "yes" to Section F, item 1, did you attach Schedule C? 9. Tax - If you want to elect a Federal Income Tax withholding rate, did you attach a W-4 form? 10. Court or Administrative Order(s) - If you answered "yes" to Section C, item 2 and/or "yes" to Section E, Item 1b, did you attach a copy of the order(s)? CSRS/FERS Handbook for Personnel and Payroll Offices 3107-107 Previous editions are not usable. Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Schedules A, B and C 1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number Schedule A - Military Service Information 1. If you have performed active honorable service in the United States Armed Services or other uniformed services, complete 1a - d below and attach a copy of your discharge certificate or other certificate of active military service (if available). See instructions for definitions of Armed Services and Uniformed Services. a. c. b. Branch of service 2. Serial number Dates of active duty From (mm/dd/yyyy) To (mm/dd/yyyy) d. Last grade or rank If any of your military service occurred on or after January 1, 1957, have you paid a deposit to your agency for this service? (You must pay this deposit to your agency. You cannot pay OPM after you retire.) Yes No Schedule B - Military Retired Pay 1. If you are receiving or have applied for military retired or retainer pay (including disability or retired pay), complete Parts 1a - 1d below. a. Are you receiving or have you ever applied for military retired or retainer pay? (Answer "yes" if you are receiving payments from the Department of Veterans Affairs instead of military retired pay.) c. Was your military retired pay or retainer pay awarded for a disability incurred in combat or caused by an instrumentality of war and incurred in the line of duty during a period of war? Yes b. Was your military retired or retainer pay awarded for reserve service under Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10)? d. Are you waiving your military retired or retainer pay in order to receive credit for military service for FERS retirement benefits? Yes (Attach a copy of notice of award) No Yes (Attach a copy of notice of award) No No Yes (Attach a copy of your request for waiver and a copy of military finance officer's acknowledgment or approval of your request for waiver) No Schedule C - Federal Employees Compensation Information 1. Are you receiving or have you ever received workers' compensation from the Office of Workers' Compensation Programs (OWCP), Department of Labor, because of a job-related illness or injury? Yes (complete parts 1a - c below) No (go to question 2) b. a. Compensation claim number c. Benefit received From (mm/dd/yyyy) Type of benefit To (mm/dd/yyyy) Scheduled award Other Total or partial disability compensation Scheduled award 2. a. Awaiting OWCP decision b. Claim denied Compensation claim number Compensation claim number 3. Other Total or partial disability compensation If you have applied for workers' compensation (other than as listed in item 1a above) but are not receiving benefits, check reason below and give the information requested. Date claim denied (mm/dd/yyyy) Except for scheduled compensation awards, workers' compensation and FERS retirement benefits cannot be paid for the same period of time. Please complete the information below regarding your claim. You must complete this section. a. Do you agree to notify us promptly if the status of your workers' compensation claim changes? b. Do you authorize the Office of Personnel Management and/or the Office of Workers' Compensation Programs (OWCP) to collect any overpayment if we later find you are not eligible for both compensation and annuity payments covering the same period of time? Yes Yes No No Applicant's Certification I certify that all statements made on these schedules are true to the best of my knowledge and belief. CSRS/FERS Handbook for Personnel and Payroll Offices Signature (do not print) 3107-107 Previous editions are not usable. Date (mm/dd/yyyy) Standard Form 3107 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Office of Personnel Management 5 CFR Part 841 Certified Summary of Federal Service Federal Employees Retirement System Federal Employees Retirement System Information for the Agency Instructions for the Employee 1. A certified copy of this form must accompany the employee's Application for Immediate Retirement (SF 3107). 2. This form may also be used: 1. 2. 3. • • 3. for retirement counseling purposes to respond to an employee's request for a record of creditable service Your employing office will complete and certify this form for you. Review this form carefully. Be sure it contains all of your service. Complete Section E, Employee's Certification, and return the form to your employing office. See the CSRS and FERS Handbook for Personnel and Payroll Offices for detailed instructions for completion and disposition of this form. Section A - Identification 1. Name of employee (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number 4. List all other names used (maiden name, AKA, spelling variants) 5. Other birth dates used 6. Military serial number 7. Service computation date for retirement purposes 8a. Did this employee elect to transfer to FERS? No 8b. If the employee elected to transfer to FERS, is the employee entitled, according to your records, to have part of the FERS annuity computed under CSRS rules? Yes, give effective date of election: Yes 9a. Does the applicant receive military retired pay? No 9b. If yes, has the applicant waived military retired pay to credit military service for FERS retirement? Yes (Attach a copy of the applicant's military retired pay order, if available, and complete 9b.) Yes (Attach a copy of the military finance center's letter to the employee accepting waiver, if available.) No No (Include cases where a waiver is not necessary.) Section B - Verified Service History Documented in Official Personnel Records Federal agency or military service branch Appointment, separation, or conversion dates for civilian and active honorable military service From To (mm/dd/yyyy) (mm/dd/yyyy) Name of retirement system* Remarks and non-creditable time** * Give details of creditable civilian service not subject to retirement deductions in Section C. **In Remarks, show if CSRS service on or after January 1, 1984, is "regular" CSRS or CSRS Offset. Indicate if service is part-time. If service was performed on a WAE or intermittent basis, show the number of days worked in "Remarks." If the number of days worked is not available, then show the number of hours worked. CSRS/FERS Handbook for Personnel and Payroll Offices 3107-107 Previous editions are not usable. Standard Form 3107-1 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Section C - Detail of Civilian Service Not Subject to Contributory Retirement System for Civilian Federal Employees Detail below (1) any period of Federal civilian service subject only to "FICA" deductions, and (2) any other Federal civilian service not subject to a Federal employee (or D.C. Government) retirement system. If total basic salary earned for any such period of service is known, you may make a summary entry on the right hand side below. Otherwise, show each change affecting basic salary during the period of service. Show part-time tour of duty, if applicable. Also provide total number of hours the employee worked during the period of part-time service, if available, and show what a full-time tour of duty would be. Service which is not subject to FERS or CSRS deductions is creditable only as specifically allowed by law. Nature of action (Appt., pro., res., etc.) Effective date (mm/dd/yyyy) Basic salary rate Salary basis (per annum, per hour, WAE, etc.) Leave without pay If basic salary actually earned is available make summary entry below From (mm/dd/yyyy) To (mm/dd/yyyy) Total earned Section D - Agency Certification I certify that the information on this form accurately reflects verified information contained in official records and that the applicant has sufficient service to be entitled to an annuity. I further certify that all required documentation in support of this application is attached, accurate and complete. Agency name and address, including ZIP Code, telephone number (including area code), FAX number, and email address Signature of authorized agency personnel official Official Title Date (mm/dd/yyyy) Section E - Employee's Certification The service listed is complete. I have additional service. (If you claim additional service, attach signed statement(s) giving dates, positions, titles and locations of employment, including agency, bureau, and division. Claimed service cannot be credited for retirement until it has been verified. This includes unverified service listed on an SF 144, Statement of Prior Federal Civilian and Military Service, or similar affidavit.) Note: If you have performed Federal civilian service subject to social security deductions (FICA) or not subject to retirement deductions, be sure that your agency has correctly completed Section C above. Signature (do not print) CSRS/FERS Handbook for Personnel and Payroll Offices Date (mm/dd/yyyy) 3107-107 Previous editions are not usable. Reverse of Standard Form 3107-1 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Spouse's Consent to Survivor Election Instructions: If you are married and you do not elect a reduced annuity to provide a maximum survivor annuity for your current spouse, complete Part 1. Have your spouse complete Part 2. Part 2 must be completed in the presence of a Notary Public or other person authorized to administer oaths. The person administering oaths must complete Part 3. Part 1 - To Be Completed by the Retiring Employee Name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number I have elected: (Mark the box(es) which describes the survivor election(s) you have made. More than one box may be marked.) a. No regular or insurable interest survivor annuity for my current spouse. I understand that: ™ ™ ™ No survivor annuity will be paid to my spouse after my death, His/her health benefits coverage will terminate upon my death, and He/she will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) after my death. b. An insurable interest annuity for my current spouse, but no regular survivor annuity for my current spouse. (I have completed Section D, item 4 on my Standard Form 3107 naming my current spouse.) c. A partial survivor annuity (25%) for my current spouse. d. A maximum survivor annuity for my former spouse _________________________________________________________. e. A partial survivor annuity for my former spouse _______________________________________________________ equal to 25% of my annuity. (name of former spouse) (name of former spouse) f. A partial survivor annuity for my former spouse _______________________________________________________ equal to 25% of my annuity. (name of former spouse) Part 2 - To Be Completed by the Current Spouse of the Retiring Employee I freely consent to the survivor annuity election described in Part 1. I understand that if my spouse elected no regular or insurable interest survivor annuity in Part 1.a. above, I will not receive a survivor annuity, my health benefits coverage will terminate and I will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) if I am not already enrolled before my spouse's death. I also understand that my consent is final (not revocable). Name (type or print) Signature (do not print) Date (mm/dd/yyyy) Part 3 - To Be Completed by a Notary Public or Other Person Authorized to Administer Oaths I certify that the person named in Part 2 presented identification (or was known) to me, gave consent, signed or marked this form and acknowledged that the consent was freely given in my presence on this the __________ day of _________________________, __________, at _______________________________________________________. (Month) (Year) (City and State) (Seal of Notary Public or witnessing authority of person authorized to administer oaths) Signature (do not print) (Seal) Expiration date (mm/dd/yyyy) of commission, if Notary Public General Information: The law requires that a retiring, married employee must elect to provide a survivor annuity for a current spouse, unless the current spouse consents to an election not to provide the maximum survivor benefit. A court order which requires a retiring employee to provide a survivor annuity for a former spouse is not an election and spousal consent is not required. In other words, such a court order does not require a current spouse to waive the right to a survivor annuity for the current spouse even though the Office of Personnel Management (OPM) must honor the terms of the court order before it can honor the election for the current spouse. The current spouse may, therefore, receive a smaller annuity than elected, or none at all, unless the former spouse loses eligibility for the court-ordered survivor annuity (through remarriage before age 55 or death). Important: If the current spouse consents to an election to provide no survivor annuity or a partial survivor annuity and is later divorced from the retired employee, the retired employee may not then elect (nor can OPM honor a court order) to provide a former spouse annuity which exceeds the amount elected at retirement for that spouse. This also applies if the parties remarry. Privacy Act Statement Solicitation of this information is authorized by the Federal Employees Retirement law, (Chapter 84, title 5, U.S. Code), the Federal Employees Group Life Insurance law (Chapter 87, title 5, U.S. Code) and the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a unique identifiable claim file. The 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. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number. The Government may use your number in collecting and reporting amounts that you owe the Government. Furnishing the Social Security Number, as well as other data, is voluntary, but failure to do so may delay or prevent action on the retirement application. 3107-107 Standard Form 3107-2 CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Agency Checklist of Immediate Retirement Procedures Federal Employees Retirement System Federal Employees Retirement System Section A - Employing Office Checklist: To be completed by office maintaining Official Personnel Folder (OPF). 1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 4. Type of retirement 5. Special provisions (Check any applicable) 3. Social Security Number 6. Immediate Voluntary (MRA+30, 60+20, 62+5) 25 Years Law Enforcement/Firefighter Immediate Voluntary (MRA+10 with age reduction) 20 Years Law Enforcement/Firefighter and age 50 Early Retirement (Major RIF, reorganization, or transfer of function) 25 Years Air Traffic Controller Involuntary Retirement Pay Plan and Occupational Series Code at Retirement 20 Years Air Traffic Controller and age 50 7. Disability Is the applicant eligible to continue health benefits coverage into retirement? Other: ____________________________ 8. Yes, enrollment code: ________________ No, give reason: _______________________________________________ Does the applicant meet the requirements for the continuation of life insurance into retirement? Yes, complete 8a. 8a. The applicant can continue Basic Life insurance and the following options: No, give reason: _______________________________________________ No optional insurance Option B - Additional with the following multiples of pay: 9. Option A - Standard Option C - Family with the following multiples of pay: 1 2 3 4 5 Are the following documents attached or actions taken? Indicate by an "X" for each item. 1 2 3 4 5 Attached Not Applicable Attached Not Applicable a. SF 3107* b. All documents applicant shows as attached to SF 3107 c. If applicant is married and elects less than the maximum survivor benefit, SF 3107-2* d. SF 3107-1* e. If discontinued service retirement, documentation specified in Chapter 44, CSRS/FERS Handbook for Personnel and Payroll Offices, including OPM Form 1510* and attachments, if available.  f. If early optional retirement, enter OPM Authority Number here g. Agency estimate of benefits, if prepared. h. If applicant has military service, DD 214 or its equivalent, if available i. If applicant wants to waive military retired pay, copy of waiver request and response from Military Retired Pay Center, if available j. If applicant served in the military, or applied for military retired pay or DOVA benefits in lieu of military retired pay, or applied for OWCP benefits, Schedules A, B, C of SF 3107. k. If applicant wants a refund of military service deposit because he/she does not want to waive military retired pay, SF 3106* l. If post-1956 military service deposit is not made, was applicant counseled about the effects of not paying the deposit? (See OPM Form 1515*) Yes No m. If applicant wants Federal Income tax withheld at the same rate as while an employee, copy of W-4 form on file with your agency. n. If the annuitant meets the 5-year requirement to continue health benefits into retirement based on previous coverage as a family member under someone else's FEHB plan or prior coverage under the Uniformed Services Health Benefits Program, attach documentation. o. If a court order requires the annuitant to provide mandatory self and family FEHB coverage for his/her children under P.L. 106-394, a copy of the court order. p. If law enforcement officer/firefighter/air traffic controller/Customs and Border Protection Officer/Nuclear Materials Courier, agency certification of service that makes the applicant eligible for an enhanced annuity benefit. q. If employee has applied for compensation benefits, OWCP award, if available 10. If the type of annuity is not disability, are the following documents attached? (Mark "X" in appropriate column.) Attached Sent to Not Applicable OWCP a. All SF 2809's* in the applicant's OPF e. All SF 54's* & SF 2823's* in the applicant's OPF b. All SF 2810's* in applicant's OPF f. All SF 2817's*, SF 176's*, SF 176T's* c. SF 2821* g. All SF 3102's* d. SF 2818* h. RI 76-10*, if applicable 11. If the type of retirement is disability, is the employee's disability documentation specified in SF 3112* attached? Yes No, explain: ______________________________________________________________________________________________________ CSRS/FERS Handbook for Personnel and Payroll Offices 3107-107 Previous editions are not usable. Standard Form 3107 - Schedule D (Page 1 of 3) Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com 12. List any documents which are attached, but not listed above: 13. Certification by Chief Personnel Officer or Designee - I certify that the above accurately reflects verified information in official records and that the applicant has sufficient service to support title to an annuity. I further certify that all required documentation in support of this application is attached, accurate and complete. Signature (do not print) Address Official Title Submitting Office Number (SON) Person to contact for further information Email address Telephone number FAX number Offenses Barring Annuity Payments: Public Law 87-299 prohibits payment of annuity to persons who have committed specified offenses involving the national security of the United States. Employing agencies are responsible for submitting all pertinent information to the Office of Personnel Management, Retirement Services, in any case when this law possibly applies. Section B - Payroll Office Checklist: To be completed by the office maintaining the Individual Retirement Record (SF 3100* and SF 3100A*) Important: The SF 3100 or SF 3100A for applicant must be closed out and sent to OPM no later than 5 days after the pay date of the final paycheck. Yes 1. Does the SF 3100 or SF 3100A for the applicant named in Section A contain all information necessary to comply with OPM instructions for maintaining the Individual Retirement Record? 2. No** Is his or her sick leave balance as of retirement shown on SF 3100 or SF 3100A? 3a. Is the applicant someone who elected to transfer to FERS and who is entitled to have a portion of his or her benefits computed under CSRS rules? 3b. If yes, are his or her sick leave balances at the time of transfer and as of retirement shown on SF 3100 or SF 3100A? 4. Is applicant's last day in pay status shown on SF 3100 or SF 3100A? 5. Is applicant's health benefits status posted on SF 3100 or SF 3100A? 6. If this is a preliminary SF 3100 or SF 3100A for disability retirement, is applicant's life insurance status posted? 7. If applicant is continuing life insurance into retirement, is the SF 2821 with Payroll Office certifying signature attached? 8a. Has applicant made a military service deposit with your agency? 8b. If yes, is an SF 3100 or SF 2806* for the deposit attached? 9a. Does the applicant have any part-time service (for an employee who elected to transfer to FERS and is eligible to have a portion of his/her annuity computed under CSRS rules, any part-time service on or after April 7, 1986)? 9b. If yes, is the number of hours in each scheduled tour of duty and the date of each change in tour of duty posted on the SF 3100 or SF 3100A (including changes to full-time and intermittent status)? If the employee worked in excess of his/her scheduled tour of duty, post the actual earnings or hours actually worked at each rate of pay. 10. If the applicant is a postal employee, are postal earnings for non-deduction service shown on SF 3100? 11. Disposition of SF 3100 or SF 3100A: SF 3100 or SF 3100A and Register of Separations and Transfers (SF 3103) are attached***. If SF 3100 or SF 3100A was already forwarded, provide the following: Forwarded to: * SF 3103 number Date (mm/dd/yyyy) of SF 3103 See page 3 of 3 for titles of forms referred to above. ** Explain any "No" responses in item 12 on the next page. ***Employees who elected to transfer to FERS may have a redesignated SF 2806 instead of, or in addition to SF 3100 or SF 3100A. CSRS/FERS Handbook for Personnel and Payroll Offices 3107-107 Previous editions are not usable. Standard Form 3107 - Schedule D (Page 2 of 3) Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com *12. Explain any "No" responses here: 13. Certification by the Chief Payroll Officer or Designee I certify that the above reflects official records maintained by this office. Signature (do not print) Payroll Office Number Telephone number Date (mm/dd/yyyy) FAX number Email address Titles of Forms Referred to in Sections A & B: SF 2806 Individual Retirement Record (CSRS) SF 3103 Register of Separations and Transfers SF 2809 Employee Health Benefits Election Form SF 3106 Application for Refund of Retirement Deductions SF 2810 SF 176, SF 176T, & SF 2817 Notice of Change in Health Benefits Enrollment SF 3107 Application for Immediate Retirement (FERS) Life Insurance Election SF 3107-1 Certified Summary of Federal Service SF 3107-2 Spouse's Consent to Survivor Election SF 2821 Continuation of Life Insurance Coverage As an Annuitant or Compensationer Agency Certification of Insurance Status SF 3112 Documentation in Support of Disability Retirement SF 54 & SF 2823 Life Insurance Designation of Beneficiary OPM Form 1510 Cert. of Agency Offer of Position and Required Doc. SF 3100 Individual Retirement Record (FERS) OPM Form 1515 Military Service Deposit Election SF 3100A Individual Retirement Record (FERS) RI 76-10 Assignment FEGLI Program SF 3102 FERS Designation of Beneficiary DD 214 Certificate of Release or Discharge from Active Duty SF 2818 Standard Form 3107 - Schedule D (Page 3 of 3) Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com