OPM 1496A Dec 2010 Markup

Form Approved
OMB No. 3206-0121

United States
Office of Personnel Management
Retirement Operations Center
Boyers PA 16017

Date of birth (mm/dd/yyyy)
Date of separation giving eligibility (mm/dd/yyyy)
Commencing date of annuity (mm/dd/yyyy)

You May Be Eligible For Deferred Retirement
Records on file with the Office of Personnel Management (OPM) indicate that you may be eligible for a deferred annuity beginning on the
"commencing date" shown above. To apply for your annuity, complete the enclosed Application for Deferred Retirement and return it to
OPM. See the enclosed information.
Your annuity will be computed under the law in effect on the date of the separation on which your eligibility for annuity is based, using
your service listed below (unless we can verify additional service). If you have additional Federal service, list it in Section D of the enclosed
application and send us copies of any documents you may have to support your claim to that service.
A decision on your eligibility for an annuity and the amount of service to your credit will be made after we receive your application.

Department or Agency and Location

Beginning Date
(mm/dd/yyyy)

Ending Date
(mm/dd/yyyy)

Civil Service Retirement Deductions were:
Withheld

Not Withheld

Refunded

Remarks:

Keep the instructions (pages 1 thru 9) for your files.
Return this letter with your completed application in the
enclosed envelope or address them to:
Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045
Prior editions are not usable.

Removed the
word Center

Retirement Operations
OPM Form 1496A
Revised December 2010

Application For Deferred Retirement
Civil Service Retirement System
(Separations on or after October 1, 1956)

Introduction
This package is for your use if you are a separated Federal
employee who wants to apply for deferred annuity based on a
separation from service covered by Civil Service Retirement law
on or after October 1, 1956. This package does not include any
information on the provisions of the Federal Employees'
Retirement System Act of 1986.
Review all information carefully before you complete the
application. Special information which applies only to certain
separated Members of Congress and congressional employees
has not been included. Keep the information sections of this
package for future reference.

Eligibility For Deferred Annuity
You are eligible for a deferred annuity if:

Item 7:

Provide your email address.

Item 8:

Indicate your citizenship.

Section B - Marital Information
Item 1:

Indicate whether or not you are married now. If you are
married, also complete Items 1a-1f with information
about your current marriage. Information about your
marital status and your spouse is necessary to assure that
you get the survivor election that you want and to which
you are entitled by law.

Item 1a:

Enter your spouse's name.

Item 1b:

Enter your spouse's date of birth (month-day-year).

1.

You had at least 5 years of creditable civilian Federal
service at the time of your final separation from a position
subject to the Civil Service Retirement law.

Item 1c:

Furnish your spouse's Social Security Number.

Item 1d:

Enter the place of your marriage (town or city and state).

2.

You were covered by the Civil Service Retirement law for
at least 1 year out of the last 2 years preceding the final
separation on which entitlement is based.

Item 1e:

Enter the date of your marriage (month-day-year).

Item 1f:

3.

You have not drawn a refund of retirement deductions
covering your final period of service.

If you were married by a clergyman or justice of the
peace, check that box. If not, check the box marked
"other" and explain how, or by whom, you were
married.

Item 2:

Indicate whether you have a living former spouse whose
marriage to you ended by divorce or annulment on or
after May 7, 1985, and to whom a court order gives a
survivor annuity. If you answer "yes," you must submit
a certified copy of the court order and any attachments
or amendments.

If your final period of service does not meet the "one out of two"
requirement, it will be eliminated from consideration, retirement
deductions withheld during the period will be refunded, and, if
possible, entitlement will be based on a previous separation. A
deferred annuity commences on your 62nd birthday, no matter
when you apply for it. If you die before attaining age 62, or after
age 62 but before applying for annuity, the only benefit payable
will be your lump-sum credit in the retirement fund; monthly
survivor annuity will not be available.

Instructions For Completing Application For
Deferred Annuity
Section A - Identifying Information
Item 1:

Type or print your name clearly.

Item 2:

List other names under which you have been
employed in the Federal government (such as
maiden name). This will make it possible for us to
locate and identify records maintained under such
names.
Enter your Social Security Number. The Treasury
Department requires us to report, by Social
Security Number, the amount paid to each
annuitant.

Item 3:

Item 4:

Enter the address to which correspondence should
be mailed. (If you want your payments sent to a
bank, do NOT enter that address here; refer to page
7 for information about how to do this.)

Item 5:

Give a telephone number where you can be reached
in case more information is needed.

Item 6:

Give your date of birth, showing the month, then the
day, then the year. Your retirement records are filed
by your name and date of birth. If your date of
birth is not correct on the letter with this package,
send proof of your date of birth (such as your birth
certificate) with your application.

Section C - Annuity Election
To be eligible for a survivor annuity after your death, your
widow(er) must have been married to you for a total of at least 9
months. The marriage duration requirement does not apply if your
death is accidental (as defined under the retirement regulations) or
your surviving spouse is a parent of your child.
Box 1: Spouse Survivor Benefit
If you initial either Box 1A or Box 1B, your wife or husband will
receive a survivor annuity upon your death. The amount of this
survivor annuity and the amount of the reduction in your annuity to
provide this benefit depend on the box you initial. For a full
discussion of the effect of court orders, see Important Information
About Annuity Election on page 2.
Box 1A: Maximum Survivor Benefit
If you initial Box 1A, you are electing the maximum survivor
benefit.
Final Separation on or after October 11, 1962
If you initial Box 1A , your spouse's survivor annuity upon your
death will be 55% of ALL of your annuity. Your annuity will be
reduced by 2-1/2% of the first $3,600 and 10% of the remainder of
your annual annuity to provide this benefit upon your death.

items rearranged and Item 7:
added.

OPM Form 1496A
Revised December 2010
Page 1

Final Separation before October 11, 1962
If you initial Box 1A, your spouse's survivor annuity upon your
death will be 50% of ALL your annuity. Your annuity will be
reduced by 2-1/2% of the first $2,400 and 10% of the remainder
of your annual annuity to provide this benefit.
Box 1B: Less than Maximum Survivor Benefit
If you initial Box 1B, you must complete and attach OPM Form
1496A, Schedule B, Spouse's Consent to Survivor Election. The
law requires consent of the spouse if a married person elects less
than the maximum survivor benefits. (See Important
Information About Annuity Election below for exceptions to the
consent requirements.)
Final Separation on or after October 11, 1962
If you initial Box 1B, your spouse's survivor annuity upon your
death will be 55% of the annual amount you specify in the blank
space (which must be less than the full amount of your annual
annuity). Your annuity will be reduced by 2-1/2% of the first
$3,600 and 10% of any additional amount you specify.
Final Separation before October 11, 1962
If you initial Box 1B, your spouse's survivor annuity upon your
death will be 50% of the annual amount you specify in the blank
space (which must be less than the full amount of your annual
annuity). Your annuity will be reduced by 2-1/2% of the first
$2,400 and 10% of any additional amount you specify.
Box 2: No Survivor Benefit
If you are married and initial Box 2, you must also complete and
attach to your application OPM Form 1496A, Schedule B,
Spouse's Consent to Survivor Election. The law requires that
your spouse consent if you elect less than the maximum or no
survivor annuity. (See Important Information About Annuity
Election below for exceptions to the consent requirement.)
If you initial Box 2, you will receive an annuity payable only
during your lifetime, without monthly survivor annuity for your
spouse. All applicants, married and unmarried, may choose this
type of annuity. However, you should review carefully all
information provided here before making your election.
Box 3: Former Spouse or Combination Current/Former
Spouse Benefit
You are not eligible to elect a survivor annuity for a former
spouse if the dates of your 62nd birthday and of the divorce or
annulment were both before May 7, 1985.
If you initial Box 3, you must use OPM Form 1496A, Schedule
A, Election of Former Spouse Survivor Annuity or Combination
Current/Former Spouse Annuity, to make your election. Read
the information at the bottom of Schedule A. You are not
permitted to elect a benefit for a former spouse who has
remarried before reaching age 55. Complete OPM Form 1496A,
Schedule B, Spouse's Consent to Survivor Election, if you are
married and initial Box 3. (See Important Information About
Annuity Election below for exceptions to the consent
requirements).
If you initial Box 3, after your death, the person(s) you elect will
receive the percentage of your annuity you select. Your annuity
will be reduced by 2-1/2% of the first $3,600 and 10% of the
remainder as you specify.

Box 4: Insurable Interest Survivor Benefit
If you initial Box 4, a person selected by you at retirement, who
has an insurable interest in you, will receive a survivor annuity
upon your death. Insurable interest exists if the person named
(such as a close relative) may reasonably expect to derive financial
benefit from your continued life. Enter the requested information
about the person selected on your application.
You must submit medical evidence that you are in good health. If
you initial Box 4, we will send you a notice describing the medical
evidence you must submit.
If you choose this type of annuity, the amount of the reduction in
your annuity will depend upon the difference between your age
and the age of the person named as survivor annuitant, as shown in
the table below. The survivor's rate will be 50% of your reduced
annuity, if final separation was before October 11, 1962; 55% if
final separation was on or after October 11, 1962.
Age of Person Named
In Relation to That of
Retiring Employee

Reduction in
Annuity of
Retiring
Employee

Older, same age, or less than 5 years younger

10%

5 but less than 10 years younger

15%

10 but less than 15 years younger

20%

15 but less than 20 years younger

25%

20 but less than 25 years younger

30%

25 but less than 30 years younger

35%

30 or more years younger

40%

If you were 62 on or after May 7, 1985, you may elect an insurable
interest survivor annuity for another person in addition to a regular
survivor annuity for a current or former spouse. However, if you
elect an insurable interest for your current spouse, you must both
jointly waive the current spouse annuity. If you elect the insurable
interest annuity for a current spouse because a court order awards
(or you have elected) the regular survivor annuity to a former
spouse, the insurable interest election for your current spouse can
be converted to a current spouse annuity if the former spouse loses
entitlement to the regular annuity through death or remarriage
prior to reaching age 55. The 9-month marriage duration
requirement does not apply to insurable interest annuities.
Important Information About Annuity Election
If you are married at retirement and do not indicate your annuity
election, you will receive an annuity reduced to provide the
maximum survivor benefit (as though you had initialed Box 1A).
If you are married at retirement and elect less than the maximum
survivor benefits for your spouse (that is, you choose 1B, 2, 3, or
4, described above), the law requires that your spouse consent on
OPM Form 1496A, Schedule B, Spouse's Consent to Survivor
Election, unless the consent requirement does not apply to you.
Your application will be processed on the basis of maximum
survivor benefits if this form is required but not attached.

OPM Form 1496A
Revised December 2010
Page 2

Notice to Applicants Whose 62nd Birthday Was Before
May 7, 1985
If your 62nd birthday was before May 7, 1985, you may not
elect a survivor annuity for a former spouse unless your
marriage terminated on or after May 7, 1985. Also, you do not
need your spouse's consent to elect an annuity without survivor
benefit for your spouse or an annuity with less than the full
survivor benefit for your spouse.
If (1) your 62nd birthday was on or after January 5, 1981, (2)
you are still married to the person to whom you were married on
your 62nd birthday, and (3) you wish to elect an annuity with
less than the full survivor benefit or no survivor benefit for that
spouse, you must enclose with your application either-> A written declaration signed by your spouse and two
witnesses to the signature (you cannot be one of the
witnesses) stating that he or she is aware that you have
elected an annuity without survivor benefit (or with less
than full survivor benefit) for your surviving spouse; or

> Your spouse's current or last-known mailing address.
Use the attached Schedule C if you need to notify your spouse
that you are electing less than the maximum survivor annuity.
Notice to Married Applicants Who Married After Age 62
Your current spouse is a spouse you married after retirement. If
you wish to elect him or her a survivor annuity, you may do so
with this application or within two years following the date of
marriage. If that two-year period has expired, this application
is your last opportunity to elect a survivor benefit for your
present spouse.
If you were not married to your current spouse on your 62nd
birthday, you may elect an annuity with less than the full
survivor benefit or with no survivor benefit (or in most cases
with survivor benefit to a former spouse, if that marriage
terminated, or your 62nd birthday occurred, on or after May 7,
1985), without the consent of, or notice to, your current spouse
or any prior spouse. If a former spouse has a court order, dated
on or after May 7, 1985, which properly awards him or her a
survivor annuity, the Office of Personnel Management (OPM)
will honor the court order.
Waiver of Spousal Consent Requirement
The spousal consent requirement may be waived if you show
that your spouse's whereabouts cannot be determined. A request
for waiver on this basis must be made in writing and
accompanied by:

>

A judicial determination that your spouse's whereabouts
cannot be determined; OR

>

Affidavits by you and two other persons, at least one of
whom is not related to you, attesting to the inability to
locate the current spouse and stating the efforts made to
locate the spouse. You must also give documentary
evidence, such as tax returns filed separately or newspaper
stories about the spouse's disappearance.

* The maximum is 50% if you separated from Federal service before
October 11, 1962.

The spouse's consent requirement may also be waived if you
present a judicial determination regarding the current spouse that
would warrant waiver of the consent requirement based on
exceptional circumstances. (Illness or injury of the retiree is not
justification for waiving the spousal consent requirement.)
Court-Ordered Former Spouse Annuities
OPM must honor a court order/divorce decree on or after May 7,
1985, that gives (awards or requires you to provide) a survivor
annuity to a former spouse. OPM cannot honor court-order
modifications issued after retirement involving a former spouse
survivor annuity. Your annuity will be reduced to provide the
survivor annuity for the former spouse. However, a former spouse
cannot receive a survivor annuity by a court order unless:
1.

He or she was married to you for at least 9 months;

2.

You have at least 18 months of service subject to retirement
deductions;

3.

He or she has not remarried before reaching age 55; and

4.

The marriage ended on or after May 7, 1985.

If you are married and a court order has awarded a survivor
annuity to your former spouse, see the section Electing a Survivor
Annuity for a Current Spouse When a Court Order Gives a
Survivor Annuity to a Former Spouse on page 4. This explains
how you can protect your current spouse's future survivor annuity
rights.
Electing a Survivor Annuity For a Former Spouse or a
Combination of Survivor Annuities for Current and Former
Spouses
If your marriage ended on or after May 7, 1985, you may elect a
reduced annuity to provide a maximum (55%* of your unreduced
annuity) or less-than-maximum survivor annuity for a former
spouse (or spouses).
1.

To make a former spouse annuity election, you must have
been married to the person for a total of at least 9 months and
you must have at least 18 months of service that was subject
to retirement deductions. A former spouse who marries again
before reaching age 55 is not eligible for a former spouse
survivor annuity.

2.

You may elect to provide a survivor annuity for more than one
former spouse. If you are married, you may elect a survivor
annuity for your current spouse as well as a survivor annuity
for one or more former spouses. However, the total of the
survivor annuities may not exceed 55% of your unreduced
annuity.

3.

To elect a reduced annuity to provide a survivor annuity for a
former spouse or a combination of survivor annuities for
current and former spouse(s), complete and attach OPM Form
1496A, Schedule A, Election of Former Spouse Survivor
Annuity or Combination Current/Former Spouse Annuity.

OPM Form 1496A
Revised December 2010
Page 3

Electing a Survivor Annuity for a Current Spouse When a
Court Order Gives a Survivor Annuity to a Former Spouse
1. If a court order has given a survivor annuity to a former
spouse, you must make your election concerning a survivor
annuity for your current spouse as if there were no
court-ordered former spouse annuity. By electing the
maximum survivor benefits for your current spouse at
retirement, you can protect your spouse's rights in case
your former spouse loses entitlement in the future
(because of remarriage before age 55, under the terms of
the court order, or death). You can do this because the
Civil Service Retirement System (CSRS) must honor the
terms of the court order and you are not required to ELECT
a survivor annuity for the former spouse. (Note: The
election you make now regarding a survivor annuity for
your current spouse cannot be changed except as
explained in the section titled Annuity Election Changes
After Retirement.) The following paragraphs explain in
more detail how your election at the time of retirement can
affect your current spouse's future rights if the court has
given a survivor annuity to a former spouse.
2.

If a court order gives a survivor annuity to a former spouse,
your annuity will be reduced to provide it. If you elect a
full or partial survivor annuity for your current spouse (or
another former spouse), your annuity will be reduced no
more than it would be to provide a survivor annuity equal
to 55%* of your unreduced annuity.

3.

If you die before your current and former spouse, the total
amount of the survivor annuities paid cannot exceed 55%
of your annuity, and the CSRS must honor the terms of
the court order before it can honor your election. The
former spouse having the court-ordered survivor benefit
would receive an annuity according to the terms of the
court order.

4.

If a court order gives the maximum survivor annuity to the
former spouse, your widow(er) would receive no survivor
annuity until the former spouse loses entitlement. Then
your widow(er) would receive a survivor annuity according
to your election.

5.

If the court order gives less than the maximum survivor
annuity to the former spouse, your widow(er) would
receive an annuity no greater than the difference between
the court-ordered survivor annuity and 55%* of your
annuity. However, if the former spouse loses entitlement to
the survivor annuity (through remarriage before age 55,
under the terms of the court order, or death), your
widow(er)'s survivor annuity would be increased to the
amount you elected.
For example, if there is a court-ordered former spouse
survivor annuity that equals 40% of your annuity, you elect
the maximum survivor annuity for your current spouse, and
you die before the former spouse's entitlement to a survivor
annuity ends, the former spouse would receive a survivor
annuity equal to 40% of your annuity and your widow(er)
would receive a survivor annuity equal to 15% of your
annuity. However, if the former spouse later loses
entitlement to the survivor annuity (through remarriage
before age 55, under the terms of the court order, or death),
your widow(er) would then receive a survivor annuity
equal to 55% of your annuity.

* The maximum is 50% if you separated from Federal service before October 11, 1962.

Electing an Insurable Interest Annuity for a Current Spouse
See the discussion on page 2 of these instructions for the definition
of Insurable Interest.
1. If a former spouse's court-ordered survivor annuity will
prevent your current spouse from receiving a survivor annuity
that is sufficient to meet his or her anticipated needs, you may
want to elect an insurable interest annuity for your current
spouse.
2.

If you elect an insurable interest survivor annuity for your
current spouse, you and your current spouse must jointly
waive the regular survivor annuity. To accomplish this:
a.

initial box 1B in Section C of the OPM Form 1496A, and
write "none" in the space following that box (i.e., election
to provide no regular survivor annuity);

b.

complete Section C, item 4 naming your current spouse
(i.e., election to provide insurable interest benefit);

c.

complete Part 1, item b of OPM Form 1496A, Schedule
B;

d.

have Parts 2 and 3 of Schedule B completed (i.e., spouse's
consent to insurable interest benefit in lieu of regular
survivor annuity).

3.

If you elect an insurable interest survivor annuity for your
current spouse and your former spouse loses entitlement
before you die, you may request that the reduction in your
annuity to provide the insurable interest annuity be converted
to the regular spouse survivor annuity; this would result in a
larger annuity. (See Annuity Election Changes After
Retirement.) Your current spouse would then be entitled to the
regular survivor annuity. In addition, if your former spouse
loses entitlement after you die, your widow(er) can ask the
Office of Personnel Management (OPM) to substitute the
regular survivor annuity for the insurable interest survivor
annuity.

4.

If for any reason OPM cannot allow your insurable interest
election for your current spouse, your current spouse will be
considered elected for a maximum regular survivor annuity
unless your current spouse signs another form consenting to
less than a maximum regular survivor annuity or OPM
approves a waiver of consent.

Annuity Election Changes After Retirement
1. Subject to the consent requirement, you may name a new
survivor or change your election if, not later than 30 days after
the date of your first regular monthly payment, you file a new
election in writing. If the person you named to receive a
survivor annuity dies or your current marriage ends through
death, divorce or annulment, you must inform OPM
immediately . Your first regular monthly payment is the first
annuity payable on a recurring basis after OPM has initially
determined the regular rate of annuity payable under CSRS
and has paid the annuity accrued since you reached age 62.

OPM Form 1496A
Revised December 2010
Page 4

2.

When the 30-day period following the date of your first
regular monthly payment has passed, you cannot change
your election except under the circumstances explained in
the following paragraphs.

3.

You may change your decision not to provide a survivor
annuity for your spouse at retirement or you may increase
the survivor annuity amount you elected for your spouse at
retirement if you request the change in writing no later than
eighteen months after the commencing date of your
annuity, and if you pay a deposit representing the
difference between the reduction for new survivor election
and the original survivor election, plus a charge of $245.00
for each thousand-dollar change in the designated survivor
base. (Interest on the deposit must also be paid.) Such an
election would cancel any joint waivers made at retirement.
However, the total survivor annuity(ies) provided for
former spouses (by court order or election) and the current
spouse cannot exceed 55% of your annuity. You may not
change your election to provide a lesser survivor benefit
for your spouse, except as discussed in item 1 on page 4.

4.

5.

6.

7.

The reduction in your annuity to provide a survivor annuity
for your current spouse stops if your marriage ends because
of death, divorce, or annulment. However, you may elect,
within two years after the marriage ends, to continue the
reduction to provide a former spouse survivor annuity for
that person, subject to the restrictions in paragraph 10. If
you marry someone else before you make this election,
your new spouse must consent to your election.
The reduction in your annuity to provide a survivor annuity
for a former spouse ends: (1) when the former spouse dies,
(2) when the former spouse remarries before reaching age
55, or (3) under the terms of the court order that required
you to provide the survivor annuity for the former spouse
when you retired. (Modifications of the court order issued
after you retire do not affect the former spouse annuity.) If
you and your former spouse were married for 30 years or
longer, the reduction does not end. However, if at
retirement you had elected a survivor annuity for your
current spouse (or another former spouse), the reduction
will be continued to provide the survivor annuity for that
person. If you have not previously made an election
regarding a current spouse whom you married after
retirement (or if your election regarding a current spouse at
retirement was based on a waiver of spousal consent), you
may, within two years after the former spouse loses the
right to a survivor annuity, elect a reduced annuity to
provide a survivor annuity for that current spouse. This
election is subject to the restrictions given in paragraph 10.
If you were not married at retirement, you may elect, within
two years after a post-retirement marriage, a reduced annuity
to provide a maximum or less-than-maximum survivor
annuity for your spouse, subject to the restrictions given in
paragraph 10. Your annuity will be reduced no earlier than
nine months after the date of your marriage.
If you were married at retirement, that marriage ends, and
you marry again, you may elect, within two years after the
remarriage, a reduced annuity to provide a survivor annuity
for your new spouse, subject to the restrictions given in
paragraph 10. Please note that the pre-divorce survivor
annuity election automatically terminates upon divorce.
You must make a new election within two years after the
divorce to provide a survivor annuity for a former spouse.
Continuing a survivor reduction, by itself, is not a former
spouse survivor election. (However, if you remarry the
same person you were married to at retirement and that
person had previously consented to your election of no
survivor annuity, you may not elect to provide a survivor
annuity for that person when you remarry.) Your annuity
will be reduced no earlier than nine months after the date of
your marriage.

* The maximum is 50% if you separated from Federal service before October 11, 1962.

8.

If, at retirement, you received (by election or court order) a
reduced annuity to provide a survivor annuity for a former
spouse and you elected to provide an insurable interest
survivor annuity for your current spouse, you may change the
insurable interest election to a regular current spouse survivor
annuity within two years after your former spouse loses
entitlement (because of remarriage before age 55, the terms of
the court order, or death), subject to restrictions a and b given
in paragraph 10.

9.

The reduction in your annuity to provide an insurable interest
annuity ends if the person you named to receive the insurable
interest annuity dies or when the person you named is your
current spouse and you change your election as explained in
paragraph 8. The reduction also ends if, after you retire, you
marry the insurable interest beneficiary and elect to provide a
regular survivor annuity for that person. If you marry
someone other than the insurable interest beneficiary after you
retire and elect to provide a regular survivor annuity for your
new spouse, you may elect to cancel the insurable interest
reduction.

10. Post-retirement survivor elections are subject to the following
restrictions:
a. They cannot be honored to the extent that they conflict
with the terms of a court order that requires you to
provide a survivor annuity for a former spouse;
b.

They cannot be honored if they cause combined current
and former spouse survivor annuities to exceed 55%* of
your unreduced annuity; and

c.

If, during any period after you retired, your annuity was
not reduced to provide a current or former spouse
survivor annuity, you must pay into the retirement
fund an amount equal to the amount your annuity
would have been reduced during that period plus 6%
annual interest.

11. Insurable interest elections are not available after retirement.

Section D - Federal Service
The letter attached to this package includes a list of your Federal
and Postal service presently included in your retirement records. If
you have performed any additional civilian Federal or Postal
service, before or after the date of final separation, list it in the
spaces provided. Attach additional sheets of paper if more space is
needed. Attach a copy of any available documentation you may
have to verify the additional service claimed. Documentation
which may be useful in verifying service includes notices of
appointment, separation or salary change. The Office of Personnel
Management will attempt to locate official records to verify your
claim even if you cannot supply documentation. If we are unable
to do so, we will let you know.
Information you give will help us to assure proper credit for all
your service.
Federal service is service as an employee of the United States
Government. Generally, to be considered an employee of the
United States Government for civil service retirement purposes,
a person must be:
a. engaged in the performance of Federal functions under the
authority of an act of Congress or an Executive Order,
b. appointed in the civil service by a Federal officer, and
c.

under the supervision and direction of a Federal officer.

OPM Form 1496A
Revised December 2010
Page 5

Section E - Military Service

a.

If you were separated from the Federal service before
October 1, 1982, we will allow credit for military service
after 1956 until you are eligible for social security. Then,
we will offset the amount of your civil service benefit that
is attributable to your post-1956 military service by any
amount of social security benefit that is also attributable
to that service. The law does not provide for you to pay a
deposit. If you are able to send us information and
documentation concerning your eligibility for social
security benefits, it may help us to process your
application more quickly.

b.

If you separated from the Federal service on or after
October 1, 1982, you had the option of paying a deposit
for post-1956 military service in order to avoid any
reduction that would otherwise take effect when you
became eligible for social security benefits. An exception
to the rule that the deposit must be paid while the
individual is still employed exists for individuals whose
final separation from Federal employment occurred
between October 1, 1982, and October 1, 1983. These
persons may pay the deposit directly to the Office of
Personnel Management (OPM).

Military service can be added to your civilian Federal service
under the circumstances outlined below:
Item 1: If you have performed active duty that terminated under
honorable conditions in the armed services or other uniformed
services of the United States, enter, for each period of active
duty, (a) the branch of service (Army, Navy, etc.), (b) your serial
number for that period of service, (c) the beginning and ending
dates of active duty, (d) your last grade or rank during that
period of service, and (e) your organization (company, division,
etc.) at discharge. If available, attach a copy of your discharge
certificate or other documentation of the active military service.
Active military service, generally rendered on a full-time basis
with military pay and allowances, includes the following:
a.

Army, Navy, Marine Corps, Air Force or Coast Guard
of the United States.

b.

Cadet or Midshipman of the United States Military
Academy, United States Air Force Academy, United
States Coast Guard Academy, or United States Naval
Academy.

c.

Regular Corps or Reserve Corps of the Public Health
Service after June 30, 1960.

d.

Commissioned Officer of the National Oceanic and
Atmospheric Administration (formerly Coast and
Geodetic Survey and Environmental Science Services
Administration) after June 30, 1961.

Service in reserve components and/or the National Guard is not
considered active Federal military service except when ordered
to active duty in the service of the Unites States and during an
initial training period. Merchant Marine service is not creditable
as military service.
Information about your active duty military service is needed so
that we can compare your claim with other records and request
verification of all claimed military service. This assures that you
are credited with the correct amount of active military service.
Deposit for Military Service
Persons who performed active duty military service after
December 31, 1956, may have paid a deposit to avoid an annuity
reduction. Read the following discussion to determine which
category describes your service. The deposit is 7% of the
military basic pay you received, plus interest at a variable rate
determined each year by the U.S. Treasury Department. Interest
is charged if the deposit is paid after October 1, 1986, or three
years after you were first employed, whichever is later. If you
did not pay your deposit while you were still Federally
employed, you cannot pay it now, unless your final separation
occurred as stated in 1.b. below.
1.

If you were first employed in the Federal service before
October 1, 1982, and

2.

If you were first employed in the Federal service on or after
October 1, 1982, you must have paid the deposit for post-1956
military service in order to receive credit for that service for
retirement purposes. In other words, unless you paid the
deposit, we will not allow credit for post-1956 military service
at the time your annuity commences, regardless of whether
you are or will become eligible for social security benefits.

Item 2: Indicate whether or not you are receiving or have applied
for military retired pay. (Military retired pay includes disability
pay.)
If you are receiving military retired pay, your military service
cannot be used for civil service retirement purposes, unless such
retired pay was awarded on account of a service-connected
disability incurred in combat or caused by an instrumentality of
war in the line of duty during a war period, or was awarded under
Chapter 1223, title 10, U.S. Code, Sections 12731 through 12739,
formerly chapter 67, title 10 (reserve retired pay at age 60 based
on 20 years of active and reserve service). If you are receiving
military retired pay and wish to combine your military and civilian
service to compute your civil service annuity, you must waive your
military retired pay.
In order to waive military retired pay you should send a written
request, specifying the effective date of the waiver and your Social
Security Number, directly to the Military Finance Center from
which you receive retired pay. Preferably this should be done at
least 60 days before the commencing date of your civil service
annuity (your 62nd birthday). Your letter might say, "I, (full name,
military serial number, and Social Security Number), hereby waive
my military retired pay for civil service retirement purposes,
effective close of business (the day before annuity commences)."
If you wish, add "I authorize the Office of Personnel Management
to withhold from my civil service retirement annuity any amount
of military pay granted beyond the effective date of this waiver
due to any delay in receiving or processing this election." This
authorization may hasten the processing of your waiver and your
retirement application.

OPM Form 1496A
Revised December 2010
Page 6

If you have already waived military retired pay in order to
receive credit for active duty military service for civil service
retirement purposes, attach a copy of your request for waiver
and of any reply you have received.

What Happens After You File Your Application
1.

The Office of Personnel Management will acknowledge
receipt of your application and give you a Retirement
Reference Card showing the claim number assigned to
your application. The claim numbers begin with the letters
"CSA." This number is very important to you; you will
need to refer to it any time you contact us in connection
with your annuity.

2.

We will search our files for all records and previous claims
related to your Federal service and place these with your
application in your CSA claim file.

3.

We will determine if any additional information is needed
to adjudicate your claim and obtain it. For example, we
may need to obtain official records of service claimed by
you but not recorded in our files, certification of your
military retired pay status, etc. We can obtain most of this
information from other Federal agencies; we will let you
know if any additional information is needed from you.
Finally, we will compute the amount of your annuity.

4.

When we finish processing your application, we will send you
a booklet explaining your benefits and any monthly survivor
benefits. This booklet contains information you will need,
including how to contact OPM to make various changes (tax
withholding, address, change in marital status, etc.)

Section F - Other Claims Information
Item 1: Indicate whether or not you have ever applied for
retirement, refund, deposit or redeposit, or voluntary
contributions under the Civil Service Retirement System. If you
have, indicate which in 1a and the applicable claim numbers in
1b. This helps to assure that all of your records are located and
that proper credit is given for your service, and for any deposit,
redeposit, or voluntary contribution payments you have made.
Item 2: Indicate whether or not you have ever been employed
under another retirement system for Federal or District of
Columbia employees. If your answer is "yes," fill in the name of
that retirement system in 2a and the dates of service in 2b. This
helps to assure proper consideration is given to all of your
service. The service you show here cannot be used to compute
your civil service annuity if the other retirement system is
paying you retirement based on the service.
Item 3: If you have applied for, or received, workers'
compensation from the Office of Workers' Compensation
Programs, U.S. Department of Labor, because of a job-related
illness or injury sustained during Federal employment, check the
"yes" box and furnish your claim numbers and dates of benefits
in 3a and 3b.
The information requested regarding benefits from the Office of
Workers' Compensation Programs is needed because the law
prohibits payment of both civil service retirement annuity and
compensation for total or partial disability under the Federal
Employees' Compensation Act at the same time. In some cases,
credit for service, particularly for periods of leave without pay,
may also be affected.

Checks will be mailed to you (or payments sent to your bank) by
the U.S. Department of the Treasury.

What To Do If Your Address Changes Before
Processing Is Completed
If your address changes, call us using the numbers on page 9 or
write us over your personal signature, giving your name, date of
birth, social security number, and your new address. Remember to
refer to your claim number. If you write to us, report your new
address to:
U.S. Office of Personnel Management
Attn: Change of Address
P.O. Box 440
Boyers, PA 16017-0440

Moved from column 2 - name changed to Section - Direct Deposit.

Section G - Direct Deposit
To have your annuity payments sent directly to a bank or financial
organization, ask us to pay you by Direct Deposit.
Having your annuity payments sent directly to your bank or
financial organization is both convenient and safe, and eliminates
the possibility of lost or stolen checks. It also assures that
payments are deposited and available for your use, even when you
are away from home. Informational material continues to be sent
to your correspondence address.

In addition, you should notify the Postal Service of your
forwarding address.

Cost-of-Living Increases
1.

Limitation on amount of increase
An annuity may not be increased by a cost-of-living
adjustment to an amount that exceeds the greater of (a) the
maximum pay payable for a GS-15 thirty days before the
effective date of the adjustment or (b) the final pay (or
average pay, if higher) of the retired employee, increased
by the overall annual average percentage adjustments
(compounded) in General Schedule rates of pay since the
employee's retirement.

2.

Determination of amount of increase and effective date.
Cost-of-Living increases are effective on December 1 and are
payable in the January annuity payment. They are determined
by the percentage increase in the average Consumer Price
Index for the "base quarter" of the year in which they are
effective over the "base quarter" of the preceding year. The
"base quarter" is July, August, and September. The first
cost-of-living increase you receive will be prorated to reflect
the number of months you are on the retirement rolls before
the increase is effective.

Section H - Certification of Applicant
Be sure to sign (do not print) and date your application, after
reviewing the warning.

Filing Your Application
Send your completed application, and any attachments requested
in the instructions or the letter, to Office of Personnel
Management, Civil Service Retirement System, Retirement
Operations Center, Boyers, Pennsylvania, 16017.

OPM Form 1496A
Revised December 2010
Page 7

Amount of Annuity

Annuity Computation

The Office of Personnel Management will compute your annuity.
See Annuity Computation for more information.

The amount of your annuity is a percentage of your average pay
(see left). The percentage is determined by a three-part formula
based on your length of creditable service. Credit is given for
whole months only, defined as 30 days. You earn:

Length of Service
Add up the years, months and days of all your periods of Federal
service, including creditable military service, before your final
separation from civilian service covered by the retirement act.
The total years and months constitute your length of service. Any
days left over, that don't make a full month, are dropped.
If you performed service for which you have been paid a refund
of retirement deductions, you may redeposit the refund, with
interest, to increase the amount of your annuity.
If redeposit is not made for service which ended before
October 1, 1990, and your annuity commences on or after
December 2, 1990, you will receive credit for the period of
service covered by the refund in your annuity computation.
However, if you do not pay the redeposit for this service, your
annuity will be permanently, actuarially reduced.
If redeposit is not made for service which ended on or after
October 1, 1990, any such period of service for which you have
been paid a refund of retirement deductions cannot be included in
your length of service unless you redeposit the refund.
In either event, we will send you information about the amount
of redeposit and its effects on your annuity and will give you an
opportunity to pay the redeposit.
If you have performed creditable service on or after October 1,
1982, during which no retirement deductions were withheld and
for which you have not paid a deposit, you will be given an
opportunity to pay the deposit, with interest.

Average Pay
Final Separation from September 30, 1956, to
October 19, 1969
Your "high-5" average pay, which is the highest average annual
pay produced by your basic pay rates during any 5 consecutive
years of service, each rate weighted by length of time it was in
effect, is used in the computation of your annuity. In most cases,
the last 5 years of service give the highest average pay, but any 5
consecutive years may be used. Within-grade periodic pay
increases are part of basic pay, but additional pay such as
overtime is not.

1.50% per year for the first 5 years, or 7.50%, and
1.75% per year for the next five years, or 8.75%, and
2.00% per year for service over ten years.
Thus, after ten years of service you have earned 16.25% [7.50% +
8.75%] of your average pay. After 8 years and 3 months of service
you have earned 13.19% of your average pay [7.50% + (1.75% X
3.25) = 13.19%]. To give another example, after 15 years and 6
months of service you have earned 27.25% of your average pay
[16.25% + (2% X 5.5) = 27.25%].
If your average pay is less than $5,000, you may substitute 1% of
your average pay plus $25 for the percentages in any or all parts of
the formula if it increases your basic annuity.
The result of the computation is your basic annuity, which must be
reduced for any or all of the applicable reasons described in the
following sections, to produce your yearly annuity rate. To find
your monthly payment amount, divide your yearly rate by 12 and
round down. Annuities based on final separations before October
20, 1969, are increased by $20.00 per month.
Reduction for Non-Deduction Service
If you have creditable service performed before October 1, 1982,
during which no retirement deductions were made from salary and
for which deposit has not been made in the retirement fund, your
basic annuity will be reduced by 10% of the unpaid deposit. The
unpaid deposit consists of the amount which would have been
withheld as retirement deductions, plus interest. This reduction
does not apply, and no deposit need be made for military service
performed before January 1, 1957. If you do not make a deposit
for civilian service performed on or after October 1, 1982, for
which no retirement deductions were made, the service cannot be
used in computing the annuity.
Reduction for Survivor Annuity
This reduction is explained under Instructions for Completing
Application, Section C, Annuity Election on page 1.
Unmarried children under 18 are usually eligible for survivor
annuity after your death. This eligibility does not depend on the
type of annuity you elect and does not reduce the amount of your
annuity.

Final Separation from October 19, 1969, to the Present
Your "high-3" average pay, computed as described in the
previous paragraph but using 3 years instead of 5, is used in the
computation of your annuity if your final separation was on after
October 20, 1969.

OPM Form 1496A
Revised December 2010
Page 8

Additional Annuity
An employee who, in addition to the amounts withheld from
salary, has made voluntary contributions to the retirement fund
will be paid, in addition to the regular annuity, $7.00 plus $0.20
for each full year the individual is over age 55 at retirement, for
each $100.00 in his or her voluntary contributions account. If an
employee elects a voluntary contributions survivor annuity, the
additional annuity purchased will be reduced based on the
difference between the annuitant's age and the survivor's age. The
survivor's additional annuity is 50% of the employee's additional
reduced annuity. Note: The additional annuity is not increased by
cost-of-living adjustments.

Payment and Accrual of Annuity
All annuities are payable in monthly installments on the first
business day of the month following the one for which the
annuity has accrued. Monthly annuity rates are rounded down to
the next lower dollar. This provision also applies to annuities that
were redetermined and to cost-of-living adjustments.

If You Need Help To Complete This Application
Write to:
U.S. Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045

You may call our Retirement Information Office toll-free at
1-888-767-6738 Monday through Friday from 7:30 a.m. to 7:45
p.m. That office is closed on Federal holidays. Callers who use
TDD equipment should call 1-800-878-5707 or within the local
calling area 202-606-0551.

Privacy Act Statement
Solicitation of this information is authorized by the Civil Service
Retirement law (Chapter 83, 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 unique identifiable claim file for you.
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 under this program, or
to report income for tax purposes. It may also be shared 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. Furnishing the data requested is voluntary. Failure to
furnish the requested information may delay or make it impossible
for us to determine your eligibility for benefits.
Public Burden Statement
We estimate this form takes an average 60 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, Retirement Services Publications Team
(3206-0121), Washington, D.C. 20415-3430. The OMB Number,
3206-0121 is currently valid. OPM may not collect this
information, and you are not required to respond, unless this
number is displayed.

We also provide retirement brochures, forms, and other
information on the Internet at www.opm.gov/retire and respond
to email sent to [email protected].

OPM Form 1496A
Revised December 2010
Page 9

Form Approved
OMB No. 3206-0121

Civil Service Retirement System

Application For Deferred Retirement
Civil Service
Retirement System

(For persons separated on or after October 1, 1956)

Please read the Instructions carefully before you complete this application.

Section A - Identifying Information
1. Name (last, first, middle)

2. List all other names used

3. Social Security Number

4. Address (number, street, city, state, ZIP code)

5. Telephone number (including area code)

6. Date of birth (mm/dd/yyyy)

7. Email address
8.

Are you a citizen of the United States of America?

Yes

Fields rearranged. Field added for email address.

8a. Name of country of which you are a citizen

No - If "No," give

Section B - Marital Information
1.

Are you married now? (A marriage exists until ended by death, divorce or annulment.)

Yes (also complete items 1a - 1f below)

No

1a. Spouse's name (last, first, middle)

1b Spouse's date of birth 1c. Spouse's Social Security
(mm/dd/yyyy)
Number

1d. Place of marriage (city, state)

1e. Date of marriage
(mm/dd/yyyy)

1f. Marriage performed by

Clergyman or Justice of the Peace
Other (explain):

Statement Regarding Former Spouses - All applicants must complete this statement if their annuities commence on or after May 7, 1985.
2.

Do you have a living former spouse(s) whose marriage to you ended by divorce or annulment on or after May 7, 1985, and to whom a court order gives a survivor
annuity?

Yes - Attach a certified copy of the court order(s) and any amendments.

No

Section C - Annuity Election
Make your election by initialing the box beside the type of annuity
you want to receive and give any other information requested.
Consider your election carefully. No change will be permitted after
your annuity is finally granted except as explained in the attached
instructions. If you are currently married and you do not elect

maximum survivor benefits, the law requires that your spouse
consent to your election. Therefore, you must complete OPM Form
1496A, Schedule B and attach it to this application. Exception:
If you were 62 on or after January 1, 1981, and before May 7, 1985,
attach Schedule C instead of Schedule B.
Initials

1. I choose a reduced annuity with survivor annuity for my spouse
equal to:

OR
Initials

A) 55% of all my annuity
(Separation on or after 10/11/62)
50% of all my annuity
(Separation before 10/11/62)
B) 55% of ________________ * a year
(Separation on or after 10/11/62)
50% of ________________ * a year
(Separation before 10/11/62)

2. I choose a self-only annuity.
(If you are married and elect this, complete and attach Schedule B or C.)

Initials

3. I choose a reduced annuity to provide a former spouse or combination
current/former spouse survivor annuity. The attached Schedule A gives
my election.
(If you are married and elect this, complete and attach Schedule B or C.)

Initials

4. I choose a reduced annuity with a survivor annuity for the person
named below who has an insurable interest in me.
(You may initial this box and also boxes 1 or 3 above.)

Initials

Name of person with insurable interest

Relationship to you Date of birth (mm/dd/yyyy)

All retiring former employees may
choose this type of annuity.

You must be healthy and willing to undergo
a physical examination if you choose this
type of annuity.
Social Security Number

* This amount must be less than your yearly annuity.
U.S. Office of Personnel Management
Previous editions are not usable

OPM Form 1496A
Revised December 2010

Section D - Federal Service
List below any Federal (or Postal) service you have performed that is NOT included in the list of your service on the form notifying you of your
eligibility for deferred retirement. Attach any documentation you may have to prove your claim to additional service.
Dept. or agency, including bureau or division

Location (city and state)

Dates of service
From (mm/dd/yyyy) To (mm/dd/yyyy)

Section E - Military Service
1.

If you have performed active, honorable service in the Armed Services or other uniformed services of the United States (see instructions for definition), complete items
1a-1e below and attach a copy of your discharge certificate or other certificate of active military service (if available).

1a.

2.

Branch of service

1b. Serial number

1c.
Dates of active duty
From (mm/dd/yyyy)
To (mm/dd/yyyy)

1d. Last grade or rank 1e.

Organization at discharge
(Div., Co., etc.)

If you are receiving or have applied for military retired pay (including disability retired pay), complete items 2a-2d below.

2a. Are you receiving or have you ever applied for military retired or retainer
pay? (Answer "yes" if you are receiving payments from the Department of
Veterans Affairs instead of military retired pay.)

Yes

2b. Was your military retired or retainer pay awarded for disability incurred in
combat or caused by an instrumentality of war?

No

2c. Was your military retired or retainer pay awarded for reserve service under
Chapter 1223, title 10? [Formerly Chapter 67, Title 10]

Yes (If available,
attach a copy of
notice of award)

Yes (If available, attach a copy of notice
of award)

No

2d. Are you waiving your military retired pay in order to receive credit for military
service for Civil Service Retirement Benefits?

Yes (See instructions for information
about how to request a waiver and its
effect on your annuity. Attach a copy of
your waiver request to this form.)

No

No

Section F - Other Claims Information
1.

Have you previously filed any application under the Civil Service Retirement System (for retirement, refund, deposit, or voluntary contributions)?

Yes (also complete items 1a and 1b below)
1a. Type of application

Retirement
Refund
2.

No
1b. Claim number(s)

Deposit or redeposit
Voluntary Contributions

Have you ever been employed under another retirement system for Federal or District of Columbia employees?

Yes (also complete items 2a and 2b below)
2a. Name of other retirement system

No
2b. Dates of service
From (mm/dd/yyyy)

3.

To (mm/dd/yyyy)

Have you ever received compensation under the Federal Employees Compensation Act?

Yes (also complete items 3a, 3b and 3c below)
3a. Compensation claim number

3b. Description of benefit

Scheduled award
Total or partial disability

No
3c. Dates benefits received
From (mm/dd/yyyy)

To (mm/dd/yyyy)

New Section G - on next page.
Certification changed to
Section H and moved to next
page.

U.S. Office of Personnel Management
Previous editions are not usable

OPM Form 1496A
Revised December 2010

Section G - Direct Deposit
1.

Public Law 104-134 requires that most Federal payments be paid by Direct Deposit through Electronic Funds Transfer (EFT) into a savings or checking account at a
financial institution, unless the payee's address is outside the United States in a country not accessible via Direct Deposit. However, if receiving your payment
electronically would cause you a financial hardship, or a hardship because you have a disability, or because of a geographic, language or literacy barrier, you may invoke
your legal right to a waiver of the Direct Deposit requirement and receive your payment by check.
Therefore, you must select one of the following:

Please send my annuity payments directly to my checking or savings account. (Go to item 2)
Receiving my payment(s) electronically would cause me a financial hardship because of a disability, or because of a geographic, language or
literacy barrier. I hereby invoke my legal right to a waiver of the Direct Deposit requirements of Public Law 104-134. Please send my payments
by check. (Go to Section H)
My permanent payment address is outside the United States in a country not accessible via direct deposit. (Go to Section H)
2.

Please provide information about your financial institution below.

2a. Financial institution routing number
2b. Account number

2c. Name and address of financial institution
Checking

2d. Telephone number of
your financial institution
(including area code)

Savings

Section H - Applicant's Certification
Warning
Any intentionally false or willfully misleading statement,
certification, or response you provide in this application 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)

I hereby certify that all statements made in this application are true to the best of my
knowledge and belief. I have read and understand all of the information provided in the
instructions to this application.
Signature (do not print)

Date (mm/dd/yyyy)

OPM Form 1496A
Revised December 2010

Election of Former Spouse Survivor Annuity or
Combination Current/Former Spouse Annuity

If you were age 62 before May 7, 1985, and your marriage ended before May 7, 1985, you are not eligible to elect a survivor annuity for that former
spouse.

Identification of Applicant
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

If your former spouse was awarded a survivor annuity by court decree or order, your annuity will be reduced to provide that benefit.
You do not need to elect a survivor annuity for that former spouse.
Election: I elect a reduced annuity to provide a survivor annuity or survivor annuities for my current/former spouse(s) as follows:
Name and address of current/former spouse

Date of marriage (mm/dd/yyyy)

Date of divorce* (mm/dd/yyyy)

Date of birth (mm/dd/yyyy)

Social Security Number

Survivor annuity
equal to
%
of my annuity

Name and address of former spouse

Date of marriage (mm/dd/yyyy)

Date of divorce (mm/dd/yyyy)

Date of birth (mm/dd/yyyy)

Social Security Number

Survivor annuity
equal to
%
of my annuity

Name and address of former spouse

Date of marriage (mm/dd/yyyy)

Date of divorce (mm/dd/yyyy)

Date of birth (mm/dd/yyyy)

Social Security Number

Survivor annuity
equal to
%
of my annuity

Total (cannot exceed 55% of your unreduced annuity)**
Signature

%

Date (mm/dd/yyyy)

* If current spouse, enter "Not Applicable."
Information: You may elect a reduced annuity to provide a full (55% of your annuity) or partial (less than 55% of your annuity) survivor annuity for a
former spouse, if you were married to that person for at least nine months and you have at least 18 months of Federal service that was subject to civil
service retirement deductions. A former spouse who marries before age 55 is not eligible for a survivor annuity.
If you are married and elect to provide a partial survivor annuity for a former spouse:
· You may also elect to provide a partial survivor annuity for your current spouse and/or former spouse(s). However, the sum of
all survivor annuities cannot exceed 55% of your unreduced annuity.
· Your current spouse must consent using OPM Form 1496A, Schedule B, to any election that does not provide him or her with
a full survivor annuity.
If you are not married, you may elect partial survivor annuities for one or more former spouses. However, the sum of all survivor annuities cannot exceed
55% of your unreduced annuity.
To elect a former spouse annuity, do not mark either box in item 1 of Section C of the OPM Form 1496A. Instead, mark item 3. Then complete and
attach this OPM Form 1496A Schedule A, which allows you to elect a benefit for a former spouse or divide the benefit between your current spouse and
former spouse(s).
Documents you must attach:
1. Copies of divorce decrees for all former spouses for whom you elect to provide a survivor annuity.
2. If you are married, you must also attach a completed OPM Form 1496A, Schedule B, Spouse's Consent to Survivor Annuity Election.

** The maximum is 50% if you separated from Federal service before October 11, 1962.
U.S. Office of Personnel Management
Previous editions are not usable

OPM Form 1496A, Schedule A
Revised December 2010

Spouse's Consent To Survivor Election
(For retirements commencing on or after May 7, 1985, under the Civil Service Retirement System)
Instructions: If you are married and do not elect a reduced annuity to provide a full current spouse survivor annuity, complete Part 1. If you mark item a,
fill in the blank to show the amount of your annuity that you entered on OPM Form 1496A, Section C. Have your spouse complete Part 2. Part 2 must be
completed in the presence of a Notary Public or other person authorized to administer oaths. The Notary Public must complete Part 3.

Part 1 - To be completed by the applicant
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

I have elected: (Mark the one box which describes the election you have made with regard to your current spouse.)

a.

A partial survivor annuity for my current spouse equal to:
(1) 55% of $ ____________ a year. (This agrees with my election in Section C, item 1B, on my completed OPM Form 1496A.)
(2) __________ % of my annuity. (This agrees with my completed OPM Form 1496A, Schedule A.)

b.

No regular survivor annuity for my current spouse, but I am electing an insurable interest survivor annuity for my current spouse. (I have
completed Section C, item 4, on my OPM Form 1496A, naming my current spouse.)

c.

No regular or insurable interest survivor annuity for my current spouse.

Part 2 - To be completed by current spouse of applicant
I freely consent to the survivor election described in Part 1. I understand that my consent is final (not revocable).
Name (type or print)

Signature (do not print)

Date (mm/dd/yyyy)

Part 3 - To be completed by Notary Public or other person authorized to take acknowledgments
I certify that the person named in Part 2 presented identification (or was known to me), gave consent, signed or marked this form, and acknowledges that
the consent was freely given in my presence on this the __________ day of _____________________, __________, at
_________________________________________________________________

(month)

(year)

(city and state)
Signature
(Seal)

Expiration date of commission, if Notary Public

General Information: Based on Public Law 98-615, a married applicant whose annuity begins on or after May 7, 1985, receives a fully reduced annuity
to provide a maximum survivor annuity for his or her spouse, unless the retiree and the spouse consent to a less than full survivor annuity by signing this
form or the Office of Personnel Management (OPM) approves a waiver of the spouse consent.
A court order which requires an applicant to provide a survivor annuity for a former spouse is not an election and spousal consent is not required. In other
words, such a court order does not require a current spouse to waive the right to a survivor annuity. The applicant can still elect to provide a survivor
annuity for the current spouse even though OPM must honor the terms of the court order before it can honor the election for the current spouse. The
current spouse may, therefore, receive a smaller annuity than elected, or none at all, unless the former spouse loses eligibility for the court-ordered
survivor annuity (through remarriage before age 55, under the terms of the court order, or death).
Important: If the current spouse consents to an election to provide no survivor annuity or partial survivor annuity and is later divorced from the retiree,
the retiree may not then elect (nor can OPM honor a court order) to provide a former spouse annuity which exceeds the amount elected at retirement for
that spouse.
Privacy Act Statement
Public Law 98-615, which establishes the spousal consent requirement, authorizes solicitation of this information. The data furnished will be used to determine the type of
annuity awarded. 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 to determine and issue benefits under their programs. 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. Failure to furnish the requested information may delay or prevent action on the retirement application.

U.S. Office of Personnel Management
Previous editions are not usable

OPM Form 1496A, Schedule B
Revised December 2010

Spouse's Notification of Survivor Election
(For retirements commencing on or after January 1, 1981, and before May 7, 1985, under the Civil Service Retirement System)
If you are married, you will receive a reduced annuity with survivor
annuity payable to your spouse in the event of your death, unless you
elect otherwise. Therefore, you may choose:

Public Law 96-391 requires that if you elect less than the maximum
survivor annuity, all reasonable attempts must be made to notify your
spouse.

a) The maximum survivor annuity which provides the surviving
spouse an annuity of 55%* of your annuity.

Complete Part 1 of this form and have your spouse complete Part 2.
Your spouse's signature must be witnessed by two people in Part 3.
You may not be a witness.

b) Less than the maximum survivor annuity, providing the
surviving spouse an annuity of 55%* of a smaller portion of
your annuity.

If you cannot obtain your spouse's signature, complete Part 4. The
Office of Personnel Management will attempt to notify your spouse as
required by law.

c) No survivor annuity to the surviving spouse.

Submit the completed Schedule C with your application.

* The maximum is 50% if you separated from Federal service before
October 11, 1962.

Part 1 - To be completed by the applicant
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

On my retirement application, I have elected (Mark "x" in appropriate box)

Less than the maximum survivor annuity.

No survivor annuity for my spouse.

Part 2 - To be completed by the spouse of the applicant
I am aware of the survivor election made by my spouse as shown in Part 1, above.
Signature (do not print)

Date signed (mm/dd/yyyy)

Part 3 - To be completed by witnesses
We, the undersigned, certify that this form was signed by the spouse of the applicant in our presence.
Signature (do not print)

Date signed
(mm/dd/yyyy)

Signature (do not print)

Name of witness (type or print)

Name of witness (type or print)

Address (number and street)

Address (number and street)

(city, state and ZIP code)

(city, state and ZIP code)

Date signed
(mm/dd/yyyy)

Part 4 - To be completed by the applicant, if the spouse's signature is unobtainable
Name and last known mailing address of spouse

Privacy Act Statement
Public Law 96-391, which establishes spouse notification requirements, authorizes
solicitation of this information. The data furnished will be used to determine the type of
annuity awarded.
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.
U.S. Office of Personnel Management
Previous editions are not usable

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. Failure to furnish the requested information may result in your receiving an
annuity with full reduction for the maximum survivor benefit.

OPM Form 1496A, Schedule C
Revised December 2010