Federal Employees Retirement System Election of Coverage Federal Employees Retirement System For Agency Use Only Section 1. Instructions for Employee: . . Complete Sections 2 and 3. Return according to your employing office's instructions. Section 2. Identifying Information (type or print) Name (Last, first, middle) Date of birth (mo, dy, yr) Social Security Number Employing Department or Agency Agency location (City, state, ZIP Code) Section 3. Verification of Receipt of Election Form (Employee's signature in this section verifies receipt of this form. It does not constitute an election.) Date Employee's signature Office telephone number After signing, return Part 1 according to employing office instructions. Do not write below this line. Instructions to Employing Office Give a copy of SF 3109 to each employee who is being reemployed after a break in service of more than three days and (1) (2) who is covered by the Civil Service Retirement System (CSRS) (either regular or offset coverage), OR whose appointment is excluded from CSRS coverage but not from Federal Employees Retirement System (FERS) coverage and who is not automatically covered by FERS (for example, term, TAPER, and certain indefinite appointments). Also give this form to employees who are converted from appointments excluded from FERS coverage (such as temporary appointments not to exceed one year) to appointments that are not excluded and who do not automatically have FERS coverage. When the signed Part 2 of SF 3109 is received, it must be filed on the right side of the employee's OPF. If the signed Part 2 of SF 3109 is not received by six months after employee becomes eligible to elect FERS coverage, Part 1 must be filed on the right side of the employee's OPF. Office of Personnel Management 5 CFR 846 NSN 7540-01-280-5503 3109-101 Part 1 - Personnel Office Standard Form 3109 July 1989 (formerly OPM Form 1555) American LegalNet, Inc. www.FormsWorkFlow.com Federal Employees Retirement System Election of Coverage Federal Employees Retirement System Section 1. Instructions for Employee . . . . . Complete this form only if you wish to elect FERS coverage. If you wish your current coverage to continue, take no action. Read information on back of Part 3. Make your election in Section 4. Complete Section 5. Be sure to sign and date in Section 6. . . . Return Parts 2 and 3 according to your employing office's instructions. Be sure to read your FERS Transfer Handbook. If you elect FERS, any CSRS designation of beneficiary (SF 2808) is cancelled. If you want to make a new designation of beneficiary, use SF 3102. Section 2. Identifying Information (type or print) Name (Last, first, middle) Date of birth (mo, dy, yr) Social Security Number Employing Department or Agency Agency location (City, state, ZIP Code) Section 3. Verification of Receipt of Election Form (Employee's signature in this section verifies receipt of this form. It does not constitute an election.) Date Employee's signature Office telephone number Section 4. Election Place your initials in the box to indicate that you want FERS coverage. I elect FERS coverage. I understand that I will be covered by (1) the Basic Benefits of FERS, (2) the Old Age, Survivors, and Disability Insurance programs of Social Security and (3) the Thrift Savings Plan. I authorize withholdings from my pay for FERS and Social Security purposes. I understand that this decision is irrevocable. Section 5. Former Spouse Information Do you have a living former spouse to whom a court order, on file at OPM, awards a portion of your annuity or, if the former spouse has not remarried before age 55, survivor benefits based on your Federal service? Yes No I don't know if a court order is on file at OPM. I request OPM to determine whether a qualified court order is on file. Attach OPM Form 1556, Former Spouse's Consent to FERS Election, your request for waiver of consent requirement, or your request for extension of election deadline in order to modify court order. Section 6. Employee's Certification I hereby certify that all statements made on this election are true to the best of my knowledge. Signature Date Warning: Any intentional false statement in this election or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years or both. (18 USC 1001) Date of receipt by agency For Agency Use Only Office of Personnel Management 5 CFR 846 NSN 7540-01-280-5503 3109-101 Standard Form 3109 July 1989 (formerly OPM Form 1555) American LegalNet, Inc. www.FormsWorkFlow.com Part 2 - Official Personnel Folder Information for Employees What is FERS? FERS is the retirement system for Federal employees established by the Federal Employees' Retirement System (FERS) Act of 1986. FERS has three parts: the basic benefit, social security, and the savings plan. The FERS Transfer Handbook (available through your employing office) is the best source of information about FERS. Before making an election, you should read this handbook. Consider your decision carefully--an election of FERS coverage is irrevocable. Complete SF 3109 only if you wish to elect FERS coverage. If you wish your current coverage to continue, take no action. When FERS coverage begins Your election of FERS coverage is effective on the first day of the pay period after it is received at the location your employing office has designated to receive it, unless there is a court order on file at OPM as described earlier and your former spouse does not consent to your election or you ask OPM to determine whether or not it has such a court order on file. If you ask for a waiver of the consent requirement and OPM grants it, your election will be effective with the first pay period after OPM notifies your employing office that it has granted your request. If you ask for OPM to determine if there is a court order on file and OPM finds that there is no court order on file, your election will be effective with the first pay period after OPM notifies your employing office that it has no such court order. Deductions Who may elect FERS coverage Generally, employees covered by the Civil Service Retirement System (CSRS) may elect to transfer to FERS within 6 months after they are reemployed following a break in service of more than 3 days or after they are converted from an excluded appointment. However, some individuals now covered by CSRS are ineligible for FERS coverag