RI20-063_June2010_MarkUp

Form approved:
OMB number: 3206-0174

Survivor Annuity Election for a Spouse
Your full name (Please print)

Your claim number
CSA

Please Provide the Following Information About Your Spouse
Spouse's full name (Please print)

Spouse's Social Security Number

Spouse's date of birth

Date of marriage (Your election must be received
within two years after this date)

Election: I elect a reduced annuity to provide a survivor annuity for my spouse named above. I have read and understand the
information in the accompanying letter and pamphlets. I understand that this election terminates if my marriage ends in divorce,
annulment, or the death of my spouse.
(Choose one of the following as a base for computing the survivor annuity.)
Use the maximum amount now available.
Use the same amount for which my annuity is now reduced.
Use the amount that will currently provide a survivor annuity rate of $____________________ per month.
(Specify a whole dollar amount.)
Important: You Cannot Revoke This Election.
Your signature (Do not print)

Date

Email address

Daytime telephone number
(

)

To elect no survivor benefit for your spouse, write your initials in the block provided and sign your name below the block.
I have read the enclosed information and have decided not to provide a survivor benefit. I have signed below.
Your signature electing no survivor benefit (Do not print)

Date

Privacy Act Statement
Title 5, U.S. Code, authorizes solicitation of this information. The data you furnish on the election letter will be used to determine your eligibility to
receive a reduced annuity and to give a survivor annuity to your spouse. This 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 to
determine and issue 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. Failure to supply all of the requested information may result in our inability to reduce your annuity for your
spouse.
We need your spouse's Social Security Number so that it may be used as an individual identifier in the Civil Service Retirement System. Executive Order
9397 (November 22, 1943) authorizes the use of the Social Security Number.
Public Burden Statement
We estimate the election takes an average 45 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 U.S. Office of Personnel Management, Retirement & Benefits Publications Team (3206-0174), Washington, DC 20415-3430. The OMB Number,
3206-0174, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Previous editions are not usable.

RI 20-63
Revised June 2010