Request for Recovery of Debt Due the United States Name of annuitant or former employee from whom collection is being sought (and other names under which employed) Social Security Number Also show name of survivor of former employee, if applicable Social Security Number Date of birth (mm/dd/yyyy) Retirement claim number Date of birth (mm/dd/yyyy) Retirement system (check one) CSRS Retirement claim number FERS CSA CSF Description of Debt Name and address to which payment should be made Date service terminated (mm/dd/yyyy) Amount of debt $ Date claim accrued (mm/dd/yyyy) Amount of each installment $ Appropriation or fund to credit (title and symbol number), if applicable Reason for debt Disbursing officer (name and symbol number), if applicable Additional interest (check one) will accrue will not accrue Due Process I hereby certify that the individual identified above owes the United States a debt in the amount certified; that procedures in 31 CFR 901, et. seq., and in 5 CFR 831.1801, et. seq., or 5 CFR 845 have been followed; and if ordered by a competent administrative or judicial authority, we will reimburse OPM or repay the debtor the amount received from OPM within 15 days of the date of the order. Check all statements that apply. The creditor agency MUST send the notice of intent to offset retirement benefits, even if there is a judgment for restitution. Date of demand letter giving notice required by 31 CFR 901, et. seq. -- -- -- -- -- -- --> Y Y _____________/________/___________ Yes No Letter included notice of intent to offset retirement benefits? -- -- -- -- -- -- --> If no, notice must be provided before recovery is requested. Letter giving notice of intent to offset retirement benefits was sent to debtor on -- -- -- -- -- -- -- -- -- --> _____________/________/___________ Judgment for restitution is attached. Debtor acknowledged debt; copy is attached. Debtor consented to collection from retirement benefits; copy is attached. Debtor did not respond; but consent to collection is assumed. Debtor requested review/hearing on -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --> Signature of agency official making certification Title Telephone number (including area code) ____________/_______/_____________ Review/hearing on _____/_____/_______ resulted in decision to collect the amount certified. No further review is available. Date (mm/dd/yyyy) Fax number (including area code) Office of Personnel Management Report of Action on Request for Recovery a. Retirement account is available for immediate set-off. OPM will make payment to you as soon as possible. b. Retirement deductions for the last known period of service have been refunded. Request for recovery has been filed for possible future action. c. Retirement account for the last known period of service has not been received at OPM. Request for recovery has been filed for possible future action. d. Debtor has not filed an application for benefits. Request for recovery has been filed for possible future action. e. Debtor has no amount to his credit in the Retirement Fund. Request for recovery has been filed for possible future action. f. We are unable to identify the debtor from the data furnished. We will make another attempt after you enter the missing items and return all copies to us. g. Other (specify) Signature of authorized OPM official Date (mm/dd/yyyy) U.S. Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices Authorized for Local Reproduction Part 1 - To Office of Personnel Management Standard Form 2805 Revised December 2005 Previous editions are not usable. American LegalNet, Inc. www.FormsWorkFlow.com