Application to Make Deposit or Redeposit OMB Approved No. 3206-0134 Civil Service Retirement System Civil Service Retirement System To avoid a delay in processing your claim: 1. Read the attached information carefully. 2. Type or print in ink. 3. Complete Part A in full and have your employing agency complete Part B. If you are not Federally employed, do not complete Part B. A. To Be Completed by the Applicant 1. Name (Last, first, middle) 2. List all other names you have used 3. Birthdate (mm/dd/yyyy) 4. Address (Number and street) 5. Department or agency in which presently or last employed 6. Social Security Number (City, state and ZIP code) 7. Location of employment (City and state) List below in chronological order all periods of civilian service for which you would like to pay a deposit or a redeposit. Department or agency, including bureau, branch, or division, where you performed the service 8. Periods of service Location Title of position (City and state) Are deductions for civil service retirement now being withheld from your salary? 9. Yes No 10. Give the dates of the period of service you want to pay for first. Beginning date (mm/dd/yyyy) Ending date (mm/dd/yyyy) If your answer is "No," give the date of separation from your last position under the Civil Service Retirement Law. Check below to indicate whether deductions were not withheld or were withheld and refunded Withheld Not withheld and refunded Date of separation (mm/dd/yyyy) Dates of Period (mm/dd/yyyy - mm/dd/yyyy) Telephone number (including area code) where you can be reached during the day Signature of applicant ( Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices The February 2001 edition is usable. All other previous editions are not usable. Date (mm/dd/yyyy) ) 2803-114 NSN 7540-00-634-4252 Standard Form 2803 Revised July 2006 American LegalNet, Inc. www.FormsWorkFlow.com B. To Be Completed by the Employing Agency Instructions to the Agency - This application is not to be used as a means for verifying service for leave, retention or other non-retirement purposes. The procedures for verifying service for establishing creditability of service are contained in Chapter 20 of the CSRS/FERS Handbook. If more space is needed for information requested in Item 3, please attach a separate sheet. Show the name and Social Security Number of the applicant on the separate sheet (SF 2801-1 may be used for this purpose). 1. Is the employee in a position subject to civil service retirement coverage? No 3. 2. Yes Exact date civil service retirement deductions began for the current appointment (mm/dd/yyyy) Civilian Service Not Under a Retirement System for Federal Employees From verified service documented in official personnel records, list any Federal civilian service not subject to a retirement system for Federal (or D.C. Government) employees. If total basic salary earned for any such period is known, a summary entry may be entered on the right-hand side below. Otherwise, show each change affecting basic salary during the period of service. Any period of nondeduction service claimed on the front of this form which cannot be verified from official records should be listed and noted in the "Leave Without Pay" column as "Unverified." NOTE: This information will also be requested (on the SF 2801-1) in connection with the employee's retirement. The agency should keep a copy of this schedule to facilitate completion of the SF 2801-1. If basic salary actually earned is available, make summary entry below. Basic Salary basis Nature of action Effective date Leave salary rate (per annum, per From To Total (Appt., pro., res., etc.) (mm/dd/yyyy) without pay hour, WAE, etc.) (mm/dd/yyyy) (mm/dd/yyyy) Earned Certification - The information entered above is based on official records of this agency and is correct. There is no official personnel or fiscal record in this agency of the additional service (if any) alleged by the employee and marked "Unverified" in item 3. Agency address Signature Date (mm/dd/yyyy) Official title Email address Telephone number (including area code) Fax number (including area code) ( ) ( ) Privacy Act and Public Burden Statement Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code). The information you furnish will be used to determine your eligibility to make deposits or redeposits to the Civil Service Retirement and Disability Fund, to identify records properly associated with your application, to obtain additional information if necessary, and to maintain a uniquely 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 the use of the Social Security Number. Failure to furnish the requested information may delay or make it impossible for us to determine your eligibility to make payments. We think this form takes an average 30 minutes per response to complete, 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 (OPM), OPM Forms Officer (3206-0134), Washington, DC 20415-7900. The OMB Number 3206-0134 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Standard Form 2803 Revised July 2006 American LegalNet, Inc. www.FormsWorkFlow.com (Detach this information sheet before filling out the application) Information Regarding Deposit and Redeposit Civil Service Retirement System Read this information carefully before filling out the attached application. Who Should Use this Application? You should use this application if you are covered by the Civil Service Retirement System (CSRS) and you want to pay a deposit or a redeposit for civilian service. You should not use this application if you are covered by the Federal Employees Retirement System (FERS). What You Should Know About Deposit for Civilian Service Under CSRS Deposit is a payment to the retirement fund to cover a period of civilian service during which no retirement deductions were withheld from your salary (also called "nondeduction" service). The amount of your deposit will be the percentage of your basic salary shown below, plus interest. You do not have to make a deposit if you do not wish to do so. However, if you do not make the deposit — • For nondeduction service performed before October 1, 1982, you will receive credit toward your retirement annuity. Your annuity will be permanently reduced by 10% of the amount due as a deposit. For example, if a deposit of $600 is required and it is not paid, the annuity is permanently reduced by $60 a year (or $5 a month). On the other hand, if a deposit of $600 is made, it will increase the annuity by $60 a year. • For nondeduction service performed on or after October 1, 1982, you will receive no credit in the computation of your annuity. The period of service will be creditable for title and average salary purposes whether or not a deposit is made. Deduction Rate Dates of Service July 1, 1926, and June 30, 1942 ........................................... 3.50% July 1, 1942, and June 30, 1948................................................. 5% July 1, 1948, and October 31, 1956 ........................................... 6% November 1, 1956, and December 31, 1969 ........................ 6.50% January 1, 1970, and December 31, 1998 .................................. 7% January 1, 1999, and December 31, 1999 ............................. 7.25% January 1, 2000, and December 31, 2000 ............................. 7.40% January 1, 2001, and December 31, 2002 ............................. 7.50% After December 31, 2002 .......................................................... 7% (Certain special categories of employees are subject to higher percentage deductions as specified in 5 U.S.C. 8334.) What You Should Know About CSRS Redeposit of service covered by the refund. If you do not pay the redeposit for this service, your annuity will be permanently, actuarially reduced because the redeposit is not paid. The amount of the reduction will be based on factors which will be divided into the amount of redeposit and interest you owe at retirement. Redeposit is a payment to the retirement fund to cover a period of service for which retirement reductions were withheld from your salary and later refunded to you. You do not have to make a redeposit if you do not wish to do so. However, if you do not make the redeposit — • • For service which ended on or after October 1, 1990, you will receive no credit in the computation of your annuity for the period of service covered by the refund. This usually results in a reduction in the amount of your annuity, or, in the event of death, your eligible widow's (or widower's) annuity. The period of service will be creditable for title and average salary purposes whether or not a redeposit is made. For service which ended before October 1, 1990, and your annuity commences on or after December 2, 1990, you will receive credit in your annuity computation for the period • If you retire on disability, you will not receive credit for service with unpaid redeposits. This means that should you retire because of a disability, you could find that you must pay for the service to receive credit for it and that the accrual of interest has increased the amount you must pay. The amount of redeposit will be the sum of the refund plus interest from the date the refund was paid to the date of redeposit (or commencing date of annuity, whichever is earlier). American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 2803 Revised July 2006 How Interest Is Computed on Deposits How Interest Is Computed on Redeposits Interest is computed on the deposit from the midpoint of each period of nondeduction service. Interest is computed on the redeposit from the date the refund was paid. • • Interest for nondeduction service performed before October 1, 1982, accrues daily and is charged at the following rates, compounded annually: • 4 percent through December 31, 1947; and • 3 percent from 1948 through the date the deposit is made or to the commencing date of annuity, whichever is earlier. • Interest for nondeduction service performed on or after October 1, 1982, accrues annually, is compounded annually on December 31 of each year, and is charged at the following rates: • At a variable rate determined annually by the Department of Treasury beginning January 1, 1985. The variable interest rate for any year equals the overall average yield to the fund from retirement securities during the preceding fiscal year. 3 percent from 1948 through the date the redeposit is made, or to the commencing date of annuity, whichever is earlier. Additional interest does not accrue if full payment is made within 30 days after the billing statement is issued. • If the refund was based on an application received by the employing agency or OPM after September 30, 1982, interest is charged beginning on the date the refund was paid, at the following rates, compounded annually: 3 percent through December 31, 1984; and • 4 percent through December 31, 1947; and • Additional interest does not accrue if payment is made in full within 30 days after the Office of Personnel Management (OPM) issues the billing statement. • If the refund was based on an application received by the employing agency or OPM before October 1, 1982, interest on the redeposit accrues daily beginning on the date the refund was paid and is charged at the following rates, compounded annually: • No interest is charged for a year when payment in full is received by December 31 of that year. 3 percent through December 31, 1984; and • A variable rate determined by the Department of Treasury beginning January 1, 1985. The variable rate for any year equals the overall average yield to the fund from retirement securities during the preceding fiscal year. For post-September 30, 1982, refunds, interest is not charged for a year when payment in full is received by December 31 of that year. Procedures Governing Civil Service Retirement System (CSRS) Deposit And Redeposit Deposits and redeposits can be made by employees now serving under the CSRS, by separated employees who are entitled (or would be entitled after paying for service) to an annuity, or by eligible widows, widowers, or former spouses of deceased employees. An applicant for retirement is automatically given an opportunity to make the deposit for nondeduction service performed on or after October 1, 1982, and any redeposit when the application for retirement is processed. An applicant for retirement must specifically request an opportunity to make a deposit for nondeduction service performed before October 1, 1982. An employee should not file an application to make deposit or redeposit if he or she contemplates retirement within six months. If you are employed by the Federal or District of Columbia Government, you must send your completed application to your department or agency first because they must certify it. If you are separated from the Federal or District of Columbia Government, send your completed application directly to the Office of Personnel Management, Retirement Operations Center, Deposit Section, P.O. Box 45, Boyers, PA 16017-0045. Instructions for making payment together with a statement for the amount due will be sent to you as soon as the processing of your application is completed. Installment payments of at least $50 are acceptable. However, interest accrues on the unpaid balance. You may authorize direct debit payments. You will receive information about how to authorize direct debit payments when you receive your statement. Specify the period of service you want to pay for first. Contact your retirement counselor to discuss the advantages of paying for one period of service over another before you make your decision. After you have paid in full for the period of service you select, please notify us if you want us to bill you for any other service. You cannot withdraw the payments you make unless you become eligible for and obtain a refund of all your retirement deductions. Additional information and assistance in completing this application may be obtained from the personnel office of the Government department or agency in which you are employed. If this source of information is not available to you, contact the Office of Personnel Management, Civil Service Retirement System, Boyers, PA 16017-0045, or call us at 1-888-767-6738 (TDD: 1-800-878-5708) Monday through Friday from 7:30 AM to 7:45 PM Eastern Time. American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 2803 Revised July 2006