Notice of Correction of Individual Retirement Record Federal Employees Retirement System Federal Employees Retirement System United States Office of Personnel Management Federal Employees Retirement System P.O. Box 45 Boyers, PA 16017 FOLD Please correct the FERS Retirement Record, Standard Form 3100, for the former employee named below: Name of Employee Date of Birth (mm/dd/yyyy) Social Security Number Agency Payroll Office No. Location (include ZIP Code) Reason for Correction: Fiscal Data Current Year Data shown on Standard Form 3100 Corrected data Amount of overstatement of total deductions Correction reported on SF 2812 Number Dated Total Cumulative Deductions Service History Data (Name, date of birth, appointment, separation, promotion, etc. -­ Specify which) Data shown on Standard Form 3100 Corrected Data Standard Form 3100 forwarded to OPM on Register: Dated: Certification I certify that the corrections shown above are correct. Signature Title Telephone Number Date U.S. Office of Personnel Management NSN 7540-01-247-2026 Standard Form 3101 Revised August 2003 American LegalNet, Inc. www.FormsWorkFlow.com