Designation of Beneficiary Form Approved OMB No. 3206-0173 Federal Employees Retirement System Federal Employees Retirement System Important: Read all instructions before filling in this form A. Identification Name (Last, first, middle) Place an "X" in the appropriate box: ¯ Date of birth (mm/dd/yyyy) An employee Retired or an applicant for retirement Social Security Number Former employee eligible for retirement in the future If you are retired give your claim number Department or agency in which presently employed (or former department or agency): Department or agency Bureau Division I, the individual identified above, designate the beneficiary or beneficiaries named below to receive any lump-sum benefit which may become payable under the Federal Employees Retirement System (FERS) after my death, including lump-sum death benefits which may become payable based on amounts contributed to the Civil Service Retirement System (CSRS) before I became covered by FERS. I understand that this designation of beneficiary cancels any previous FERS or CSRS designation of beneficiary, and that it remains in effect until I cancel it in writing or I receive payment of my FERS retirement contributions. Location (City, state and ZIP code) I direct, unless otherwise indicated below, that if more than one beneficiary is named, the share of any beneficiary who may predecease me or who may be disqualified for any other reason, shall be distributed equally among the stated beneficiaries, or entirely to the survivor. If none of the beneficiaries are alive and eligible to receive payment when a lump-sum payment becomes payable, this designation is void, and payment will be made according to the order of precedence set by law. B. Information Concerning The Beneficiaries (See Examples of Designations): First name, middle initial, and last name of each beneficiary ™ Date of designation (mm/dd/yyyy) Address (Including ZIP code) of each beneficiary š Relationship to you ™ Share to be paid to each beneficiary Your signature Total = 100% C. Witnesses (A witness is not eligible to receive payment as a beneficiary): We, the undersigned, certify that this statement was signed in our presence. Signature of witness Address (including ZIP code) Signature of witness Address (including ZIP code) Receiving agency certification I have reviewed this designation and certify that the designated shares total 100% and that no witnesses are designated as beneficiaries. Date received by agency (mm/dd/yyyy) Signature Date (mm/dd/yyyy) ™ We will pay to the person you designate, even if that person's name or relationship to you changes after you file this designation. For example, suppose you designate your spouse and then you two divorce and you marry someone else. We will pay any lump sum to your former spouse unless you submit another designation to cancel prior designations or to designate who we are to pay. š We will write to the address you provide here to contact the person you designate. However, that person is obligated to get in touch with us after your death to ask us to make payment. Type or print your return address so that we can return a copy to you. See Back of Employee Copy For Instructions On Where To File This Form. (Retain until employee leaves Federal service and then send to the Office of Personnel Management [OPM].) U.S. Office of Personnel Management 5 CFR 843.205 Part 1 - Original Copy NSN 7540-01-246-9252 3102-104 Previous editions are not usable. Standard Form 3102 Revised December 2006 American LegalNet, Inc. www.FormsWorkFlow.com Important - The filing of this form will completely cancel any Designation of Beneficiary under the Federal Employees Retirement System or under the Civil Service Retirement System you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries of any lump sum payable at your death. Examples of Designations 1. HOW TO DESIGNATE ONE BENEFICIARY Do not write names as M.E. Brown or as Mrs. John H. Brown. If you want to designate your estate as beneficiary, enter "My estate" in the beneficiary column. First name, middle initial, and last name of each beneficiary Mary E. Brown Address (Including ZIP code) of each beneficiary 214 Central Avenue Muncie, IN 47303 2. HOW TO DESIGNATE MORE THAN ONE BENEFICIARY Joseph P. Brady Catherine L. Rowe Share to be paid to each beneficiary Niece 100% Be sure that the shares to be paid to the several beneficiaries add up to 100 percent. Address (Including ZIP code) of each beneficiary 509 Canal Street Red Bank, NJ 07701 360 Williams Street Red Bank, NJ 07701 792 Broadway Whiting, IN 46394 Relationship to you Share to be paid to each beneficiary Aunt 25% Nephew 25% Mother 50% Relationship to you Share to be paid to each beneficiary Father 100% Sister 100% Relationship to you Share to be paid to each beneficiary Trustee First name, middle initial, and last name of each beneficiary Alice M. Long Relationship to you 100% Niece 100% 3. HOW TO DESIGNATE A CONTINGENT BENEFICIARY First name, middle initial, and last name of each beneficiary Address (Including ZIP code) of each beneficiary 810 New 810 Otherwise to: Susan A. Parrish New John M. Parrish, if living West 180th Street York, NY 10033 West 180th Street York, NY 10033 4. HOW TO DESIGNATE AN INTER VIVOS TRUST (A trust that you set up during your lifetime) First name, middle initial, and last name of each beneficiary Address (Including ZIP code) of each beneficiary Trustee(s) or Successor Trustee(s) as provided in the John Q. Public Trust Agreement dated 12/18/1999, if valid. Otherwise to: Mary E. Brown 214 Central Avenue Muncie, IN 47303 5. HOW TO DESIGNATE A TESTAMENTARY TRUST (A trust that is set up when you die, according to terms in your will) First name, middle initial, and last name of each beneficiary Trustee(s) or Successor Trustee(s) as provided in my Last Will and Testament, if valid. Otherwise to: Maria Sufuentes 5909 Pacific Avenue, NW Washington, DC 20019 Relationship to you Share to be paid to each beneficiary Trustee Address (Including ZIP code) of each beneficiary 100% Niece 100% 6. HOW TO CANCEL A DESIGNATION OF BENEFICIARY AND EFFECT PAYMENT UNDER ORDER OF PRECEDENCE (See back of employee copy) First name, middle initial, and last name of each beneficiary Address (Including ZIP code) of each beneficiary Relationship to you Share to be paid to each beneficiary Cancel prior designations Standard Form 3102 (Reverse of Part 1) Revised December 2006 American LegalNet, Inc. www.FormsWorkFlow.com Do not fill out this form until you have read the information and instructions below Instructions This Designation of Beneficiary Form is used to designate who is to receive a lump-sum payment which may become payable under the Federal Employees Retirement System (FERS). It does not affect the right of any person who is eligible for survivor annuity benefits. This form may not be used and will not be effective in any way to elect, or demonstrate the intent to elect, a survivor annuity for a spouse, former spouse, or an individual who has an insurable interest in an employee. Do not confuse this form with designation forms used for other types of benefits: Standard Form 2808, Designation of Beneficiary - Civil Service Retirement System; Standard Form 2823, Designation of Beneficiary - Federal Employees' Group Life Insurance Program; TSP-3, Federal Retirement Thrift Savings Plan Designation of Beneficiary; or Standard Form 1152, Designation of Beneficiary - Unpaid Compensation of Deceased Civilian Employee. This form is only for employees and retirees under FERS. Employees and retirees under the Civil Service Retirement System (CSRS) must use Standard Form 2808, Designation of Beneficiary - Civil Service Retirement System. If you transferred from CSRS to FERS and previously filed an SF 2808, Designation of Beneficiary - Civil Service Retirement System, your SF 2808 is invalid. You must file a new designation using this form. Important - The filing of this form will completely cancel any Designation of Beneficiary under FERS or CSRS (SF 3102 or SF 2808) you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries for FERS lump-sum death benefits, including lump sum payment of amounts you may have contributed to CSRS before becoming covered by FERS. Order of Precedence You do not need to make a designation if you are satisfied with the order of precedence that the law provides. That order of precedence follows: 1. To your widow or widower. 2. If your widow(er) is deceased, to your child or children, with the share of any deceased child distributed among the descendants of that child. 3. If none of the above, to your parents in equal shares or the entire amount to the surviving parent. 4. If none of the above, to the executor or administrator of your estate. 6. You cannot change or cancel a designation of beneficiary in a last will or testament unless it is signed, witnessed, and filed as described in paragraph 3. 7. A designation of beneficiary remains in effect until (1) you cancel it by filing a new designation, or (2) you receive a refund of your retirement deductions before retirement. To inform us if the name or address of a beneficiary changes, file a new designation of beneficiary. It may be important to file a new designation if your family situation changes. Completing the Designation Form 5. If none of the above, to your other next of kin under the laws of the State in which you live at the time of your death. 1. The examples printed on the back of the first page of this form may be helpful to you in naming a beneficiary or canceling a prior designation of beneficiary. Payment of a lump sum will be made to the first person or persons listed above who are alive on the day you die. 2. If you designate more than one beneficiary, be sure that the shares to be paid to them add up to 100 percent. Designating a Beneficiary 3. Complete the form in duplicate. Type or print all entries except signatures. Do not use pencil. 1. You can designate any person, firm, corporation, trust, or legal entity as your beneficiary. 4. Do not erase or alter entries. If you want to designate a trust, see examples 4 and 5 on the back of Part 1. Those examples name a contingent beneficiary in case the trust is not valid. You don't have to name a contingent beneficiary unless you want to. If the trust is not valid, and you do not name a contingent beneficiary, OPM will pay according to the order listed under "Order of Precedence" above. Where to Submit the Completed Form For employees: File this form with your employing agency, even if you are retiring. 2. You can change your beneficiary at any time, without the knowledge or consent of a previous beneficiary, and this right cannot be waived or restricted. 3. A designation of beneficiary must be in writing, signed, and witnessed. If you are an employee, the designation must be received in your employing office prior to your death. If you are a separated employee, a retiree or a person receiving recurring payments from the Office of Workers' Compensation Programs (OWCP), the designation must be received by the Office of Personnel Management (OPM) prior to your death. For separated employees, retirees and individuals receiving recurring benefits from the Office of Workers' Compensation Programs (OWCP): If you have left Federal employment, if you are receiving recurring benefits from the Office of Workers' Compensation Programs, or if you have retired, file this form with the Office of Personnel Management, Retirement Operations Center, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045. Your designation will not be effective until the date it is received by your employing agency (or OPM if you are not employed). 4. A witness to a designation of beneficiary is ineligible to receive payment as a beneficiary. 5. The person(s) named will be considered a beneficiary (beneficiaries) for both CSRS and FERS lump-sum benefits. The employee copy of this form will be noted and returned to you as evidence that the original has been received and filed. Please keep the duplicate in a safe place along with your other important papers. For the employing agency: File the Official Personnel Folder (OPF) copy on the right side of the OPF. If the employee leaves Federal service, send all FERS designations in the OPF to OPM. Privacy Act and Public Burden Statements Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and the Federal Employees Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be used to determine who will receive a lump sum benefit in the event of your death. 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 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 data may delay or make it impossible for us to determine how to make payment in the event of your death. We think providing this information takes an average of 15 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 SF 3102, including suggestions for reducing completion time, to the U.S. Office of Personnel Management (OPM), OPM Forms Officer (3206-0173), Washington, D.C. 20415-7900. The OMB number, 3206-0173 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Standard Form 3102 (Reverse of Part 2) Revised December 2006 American LegalNet, Inc. www.FormsWorkFlow.com