RI38-107_June2009MarkUp

Form Approved:
OMB No. 3206-0197

United States
Office of Personnel Management
1900 E Street, NW
Washington, DC 20415-3564

Date
Claim number

CS

URGENT — Reply Required Within 30 Days to Avoid Interruption of Your Payments
For your protection, the Office of Retirement Programs is verifying your records to make sure the annuity payments and
informational correspondence we send you are going to the right person and the correct address. If we are paying you as
the survivor of a deceased Federal employee or retiree, it is your information we are verifying. The information for the
deceased is already on file.
Please take the following actions promptly:
•
•
•
•

Verify the name and address shown above for accuracy (including spelling).
Enter the information requested in Parts A or B on page 2 of this letter.
Sign your name in the space provided.
Return this letter to the Office of Personnel Management (OPM) in the enclosed envelope.

Thank you for your cooperation in this important matter.
Retirement Inspection Branch
202-606-0249
Privacy Act and Public Burden Statements
Solicitation of this information is authorized by the Civil Service Retirement law, Federal Employees Retirement law, the
Federal Employees' Group Life Insurance Program, and the Federal Employees Health Benefits Program (Chapters 83,
84, 87, and 89 of title 5, U.S. Code). The information you furnish will be used to identify records properly associated with
your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or
future benefits, and to maintain a uniquely identifiable claim file. 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 or continuation 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 as an individual identifier to distinguish between people with the same or similar names.
Failure to furnish information may delay or make it impossible for us to determine your eligibility to receive benefits.
We estimate this form takes an average 10 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 this form, including suggestions for reducing completion time, to the Office of Personnel Management,
CRIS Publications Team (3206-0197), Washington, DC 20415-3430. The OMB Number 3206-0197 is currently valid.
OPM may not collect this information and you are not required to respond, unless this number is displayed.

Previous edition is not usable.

RI 38-107
Revised June 2009

Part A - Annuitant's Response (If the annuitant is deceased, go to Part B.)
If the annuitant cannot sign in Item 4, complete Items 1, 2, and 3 as applicable. Skip Item 4 and complete Item 5.
Item 1 - (Check one block.)
My name and correspondence address shown on the front of this notice are correct. (Complete items 2 and 4 or item 5.)
My name and/or correspondence address shown on the front of this notice are not correct. (Complete items 2, 3, and 4 or item 5.)
Item 2 - (Enter your identifying information.)

Item 3 - (Show the correct information.)

Annuity claim number

Name

Annuitant's Social Security Number

Address

Daytime telephone number (including area code)

City, State, and ZIP Code

Item 4 - Signature and Certification

I hereby certify that the above information is true to the best of my knowledge and belief.
Annuitant's signature (do not print)

Date (mm/dd/yyyy)

Warning: Any intentionally false statement made above 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 U.S.C. 1001)
Item 5 - If it is not possible for the annuitant to sign, provide the information requested below.
Reason the annuitant cannot sign
Printed name of person replying

Relationship to the annuitant of person replying

Address of person replying
City, State, and ZIP Code

Daytime telephone number of person replying (including area code)
Date (mm/dd/yyyy)

Signature of person replying on behalf of the annuitant

Warning: Any intentionally false statement made above 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 U.S.C. 1001)
Part B - Deceased Annuitant (If the annuitant has died, give the following information.)
Date of death (mm/dd/yyyy)

Place of death

Include a copy of the death certificate.
Signature

Date signed (mm/dd/yyyy)

Your printed name and address

Telephone number (including area code)

Page 2 of RI 38-107
Revised June 2009