2005 Marital Status Certification Survey - mark up

Form Approved

OM B NO. 3206-0033

2005 Marital Status
Certification Survey
Show any address change
next to your address below.

Claim Number
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Case Name

You DO NOT need to send this form back if you have never remarried,
Please read the back of this form before completing your answers below. ONLY check the items that
apply to you. Please enter the month, day, and year in the boxes provided. Enter a leading zero for
months and days with only one numhr, for example, March 7, 2003, would be 0310712003.

I remarried before I reached age 55 and this is my first time notifying OPM. The date of my
remarriage is:

U l ~ u l l
m

m

d

d

Y

Y

Y

Y

Although I remarried before I reached age 55, 1 was married to the person named
above for at least 30 vears. We were married on the followina date:
m

m

d

d

Y

Y

Y

Y

Answer only if you have NEVER reported your remarriage to OPM. 0 0 NOT SEND THIS FORM BACK
IF WE ALREADY HAVE THlS INFORMATION AND THE PROOFS WE NEED.
I remarried before I reached age 55 and this is my first time notifying OPM. This marriage
has since ended. The date of my remarriage is indicated below.
Date of Remarriage

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L - - -

m

m

m

m

d

d

Y

Y

Y

Y

d

d

Y

Y

Y

Y

This marriage ended

(Please attach a copy of the document showing the date the marriage ended by death, divorce, or
annulment.)
WARNING: We may verify your marital status through a computer match with other Federal agencies. Any intentionally false or
misleading statement, certification, or response you provide 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 (f8 USC 1001).
I certify that all information 1 gave on this form is true and correct to the best of my knowledge and belief.

IDaytime Telephone Number

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If you are a surviving spouse who married before you were age 55, even if
that marriage has ended, you must report your remarriage to OPM. If you
have already notified OPM of the change in your marital status, please DO
NOT return this form.

We contact you periodically to remind you of the eligibility requirements for you to continue receiving a survivor
annuity. By law, you may continue receiving this annuity ONLY as long as you do not remarry before your 55th
birthday un\ess you were married to the decedent for at least 30 years prior to his or her death. You are
responsible for notifying us immediately of remarriage. Failure to notify us immediately will result in an
overpayment of annuity. You will be held liable for full repayment of any and all annuity paid to you after the
remarriage.
SHOULD YOU RESPOND TO THIS SURVEY FORM?

If you remarried before reaching age 55 and you have not already notified us of that remarriage, you need to
complete and return this form within 30 days after the date on the front. Otherwise, do not return this form.
Example: You remarried in 1986 and notified us. We terminated your survivor benefits. This remarriage
ended in 1993. Again, you notified us and we reinstated your survivor benefits. You do NOT need to
complete and return this form.
INFORMATION ON COMMON LAW (MUTUAL CONSENT) MARRIAGE

If you live in a state that: recognizes a common law (mutual consent) marriage, we must treat it the same as a
marriage by a civil or church ceremony. To prove common law marriage, you must have presented yourselves as
man and wife, supply two affidavits swearing you are married from persons who are in a position to know, and
send us at least two of the following: copies of taxes filed jointly, joint bank account, joint contract for purchase of a
home, joint lease for rental of an apartment or house.
NEED HELP?

If you need help, please contact our office at (202) 606-0249. If you are calling from outside the Washington DC
area, you can call our Retirement Information Office toil free at 1-888-767-6738 from 7:30AM to 5:30 PM, Eastern
Time. If you prefer, you can write us at this address: U.S. Office of Personnel Management, Retirement Surveys
and Students Branch, 1900 E St., NW, Washington DC 20415-3562. You may also fax your response to (202)
606-0022.

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Privacy Act and Public Burden Statement
furnish will be used to determine your eligibility to continue receiving survivor annuity payments. Information may be
Information
shared and is subject to verification, via paper, electronic media, or through the use of computer matching prwrams, with national, state,
local, or other benefit paying agencies I n order to determine and issue benefiis under their programs, to obtain information necessary for
continuation of benefits unbr this program, or t o report income for tax purposes. It may also be shared and verified, as noted abwe,
with law enforcement agencies when they are investigating a violation or potential violation of civil w criminal law. 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, tltle5 U.S. Code). Failure to furnish the requestedinfwrnationmay causean overpayment of annuity. We will haveto
collect any overpayment from you.
We think providing this information takes an average 15 minutes per response, including the time for reviewing instructions, gett lng the
needed data, and reviewing the requested information. Send comments regarding our estimate w any other aspect of this form,
including suggestions for reducing cmpIetion time, to the United States Office of Personnel Management (OPM), OPM Forms Officer
(3206-0033),
Washington, DC 20415-7900. The OMB number, 3206-0033, is curently valid. OPM may not collect this information, and you
are not required to respond, unless this number is dispIayed.

Reverse o f RI 25-7
Revised A u g u s t 2005