RI20-116_August2000_MarkUp

Form approved
OMB Number: 3206-0174

United States
Office of Personnel Management
Retirement Operations Center
P. O. Box 45
Boyers, PA 16017-0045

Date
CSA No.

•

This is in response to your request for information on providing a survivor annuity of $___________
per month for your spouse. If you make this election, your annuity will be adjusted as shown below.
1. Your current gross monthly annuity rate is $_______________.
2. If you make this election, your gross monthly annuity will be reduced to $_______________.
3. Your spouse's gross monthly annuity will be $_______________. Future cost-of-living adjustments
will be applied to this rate.
If you want to provide this survivor annuity, please complete the enclosed election form and return it to
us before _____________. We have enclosed a copy of the information we sent you on ____________.
Return this election form to:
U.S. Office of Personnel Management
Retirement Operations Center
Attn: PRM-STOP
P.O. Box 45
Boyers, PA 16017-0045
If you decide not to provide a survivor benefit, please indicate your decision below, provide your
signature and date, and return this letter to us at the above address.
Name (Please print)

I have decided not to provide a survivor benefit for
Signature (Do not print)

Date

Sincerely,

Benefits Specialist
Retirement Operations Center
(724) 794-2005, Ext.___________
Enclosure: RI 20-63 - Survivor Annuity Election for a Spouse
Copy of information we sent you before.
RI 20-116
August 2000