Civil Service Retirement System APPLICATION TO MAKE VOLUNTARY CONTRIBUTIONS Civil Service Retirement System 2. Date of birth (mm/dd/yyyy) (1) Type or print in ink. (2) Answer all the questions. 1. Name (Last, first, middle) 4. Address (Number, street, city, state, and ZIP code) 3. Social Security Number 5. List all other names you have used (Include maiden name, if applicable.) 6a. 7a. Do you have any civilian government service during which no Civil Service Retirement deductions were taken from your salary? Do you have any service during which Civil Service Retirement deductions were taken from your salary and later refunded to you? Have you ever made voluntary contributions and later received a refund of them? Yes No Yes No Yes No 6b. Have you made a deposit to the Civil Service Retirement and Disability Fund to cover this non-deduction service? 7b. Have you made a redeposit to the Civil Service Retirement and Disability Fund of the amount refunded to you? 8b. Have you since been separated from the government service for a period of more than 3 calendar days? Yes No Yes No Yes No 8a. If your answer to question 6b, 7b, or 8b is "No", do not file this application. See the attached information. Agency Certification I certify that the applicant is an employee of the agency shown below, is in a position subject to the Civil Service Retirement System, and has answered question 6a correctly. Agency address Signature Official title I hereby apply to make voluntary contributions to the Civil Service Retirement and Disability Fund. I am employed in a position subject to the Civil Service Retirement System or I am an applicant for retirement under the Civil Service Retirement System. I have read the information on the attached page. Applicant's signature (Do not print) Date Telephone number Date ( Privacy Act Statement ) Title 5, U.S. Code, Chapter 83, Civil Service Retirement authorizes the solicitation of this information. The data you furnish will be used to identify records properly associated with this application, to obtain additional information if necessary, and to determine if you are eligible to make voluntary contributions to the Civil Service Retirement and Disability Fund. 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. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number. Failure to supply all of the requested information may delay or prevent approval of your application. You need to read the attached information so that you understand the effect of making voluntary contributions. Ask your personnel office if you are employed and need more information. If a personnel office is not available, contact the Office of Personnel Management at the address given or call 1-888-767-6738 (TDD: 1-800-878-5707). U.S. Office of Personnel Management CSRS and FERS Handbook for Personnel and Payroll Offices The July 1999 edition is usable. All other previous editions are unusable. See the Attached Information Sheet NSN 7540-00-634-4253 2804-110 SF 2804 Revised July 2006 American LegalNet, Inc. www.FormsWorkFlow.com Information Regarding Voluntary Contributions Civil Service Retirement System Filing Your Application If you are an employee, you must submit the completed form to your agency personnel office. They will complete the agency certification box and forward your application to the Office of Personnel Management. If you are already separated for retirement and are waiting for your retirement application to be approved, no agency certification is needed. Send your application to: U.S. Office of Personnel Management Retirement Operations Center PO Box 45 Boyers, PA 16017-0045 Limit on Contributions Your total contributions cannot be more than 10 percent of the total of your basic civilian salary received as of the date any contribution is made. You cannot make contributions based on anticipated future earnings. OPM will compute your limitation when you retire or close out your account. We will accept the contributions you make; however, when you retire or close out your account, any amount found to be in excess of your limit will be refunded, without interest. Refund of Contributions You may apply for and be paid a refund of all (not just a part) of your voluntary contributions plus earned interest at any time before you retire and receive additional annuity. Please note that you will not receive interest on the amount of your deposits that exceed the 10 percent limitation. If you are paid such a refund, your account is closed. You cannot open another account or again make voluntary contributions unless you are separated for more than 3 calendar days and are then reemployed in a position subject to CSRS. Interest Your voluntary contributions account earns interest at a rate of 3 percent a year through December 31, 1984. Thereafter, your account earns interest at a rate equal to the average yield earned by new investments purchased by the Civil Service Retirement and Disability Fund during the preceding fiscal year. Interest begins to accrue on the date your voluntary contributions are deposited in your account. Interest is compounded annually on December 31 of each year. This interest is not subject to Federal income tax until it is paid to you. As a general rule, your voluntary contributions stop earning interest on the earliest of the following dates: (1) the date OPM authorizes payment of a refund of your voluntary contributions; (2) the date you separate from Federal service; or (3) the date you transfer to a position not subject to CSRS (or FERS). Sole exception: if you separate from Federal service with entitlement to a deferred annuity commencing at age 62 and do not elect a refund of voluntary contributions, interest will continue to accrue to your annuity commencing date (62nd birthday) or your death, whichever is earlier. (Note: In the case of a separated employee with title to a deferred annuity who receives a refund of voluntary contributions -- either before or after reaching age 62 -- the general rul