Form RI 92-19 RI 92-19 Application for Deferred or Postponed Retirement

Form Approved:
OMB number 3206-0190

Application for Deferred or Postponed Retirement
Federal Employees Retirement System
This application is for you if you are a former Federal employee who was covered by the Federal Employees Retirement System (FERS) and
you wish to apply for your retirement annuity. You should complete this application if you choose to apply for an annuity which will begin
more than 1 month after your separation from Federal service (or transfer to a position not covered by FERS) and:
1.

you have completed at least 5 years of creditable civilian service and are eligible for a deferred retirement at age 62; or

2.

you have completed at least 10 years of creditable service, including 5 years of civilian service, and are eligible for an annuity at the
Minimum Retirement Age (MRA).

Send your completed application (approximately 60 days before you want your benefits to begin) to:
Office of Personnel Management
Federal Employees Retirement System
P.O. Box 45
Boyers, PA 16017-0045
You should have received the informational pamphlet RI 92-19A, Applying for Deferred or Postponed Retirement Under the Federal
Employees Retirement System, with this application. If you did not receive this pamphlet, you can access the pamphlet on our website at
www.opm.gov/Forms/. You can also get a copy by calling the Office of Personnel Management (OPM) at 1-888-767-6738 or by contacting
us at the address above. If you use TTY equipment, call 1-800-878-5707.
If your address changes before you receive your claim number, write to us giving your name, date of birth and Social Security Number.
If you have received your claim number, remember to refer to it.

Instructions for Completing Application for
Deferred or Postponed Retirement
Type or print clearly. If you need more space in any section, use
a plain piece of paper with your name, date of birth, and Social
Security Number written at the top. If you do not know an answer
write “unknown.” If you are uncertain of any information you provide,
answer to the best of your ability, followed by a question mark (?).

Item 3:

The following information should help you to answer the questions on
the application which are not self-explanatory.

Item 1:

Section A - Identifying Information
Item 2:

Item 3:

List other names under which you have been employed
in the Federal government (such as a maiden name).
This will help us to locate and identify all your records.
Enter the address to which correspondence should be
mailed. If you want your payments sent to a bank, do not
enter the bank address here; complete Section H of this
application.

List all Federal civilian service that you have performed.
Give the bureau and/or division as well as the name of the
agency, along with the agency’s location and the beginning
and ending dates of the service.

Section C - Military Service
Indicate whether you have performed active duty that
terminated under honorable conditions in the armed services
or other uniformed services of the United States, including
the following:

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

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

Section B - Federal Civilian Service
Item 2:

Show the agency where you performed your last Federal
service. Give the bureau and/or division as well as the name
of the agency and include its location (city, state.)

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

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

Previous editions are not usable

RI 92-19
Revised June 2008

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 United States and
during an initial 4-month training period.
Item 2:

Item 4:

Section D - Other Claim Information
Item 3:

Persons who performed active military service after
December 31, 1956, must have paid a deposit to receive
credit under the Federal Employees Retirement System
(FERS) for their military service. You must have paid your
deposit to your former employing agency. If you did not pay
your deposit while you were still a Federal employee, you
cannot pay it now. If you have military service performed
after 1956, which is covered by a deposit you paid as an
employee, check “Yes” and continue with this section. Items
2a and 2b will help us locate records of your payment.
Indicate whether you are receiving or have applied for
military retired or retainer pay (including disability retired
pay.)
If you are receiving military retired pay, your military
service cannot be used for retirement purposes unless your
retired pay was awarded because 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,
formerly Chapter 67, title 10 and title III of Public Law
80-810 (reserve retired pay at age 60 based on 20 years of
active and reserve service). Otherwise, to receive credit for
your military service, you must waive your military retired
pay.
To waive military retired pay for FERS retirement purposes,
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.
Attach a copy of your letter to this application. You should
mail this letter at least 60 days before your annuity will
begin. Your letter might say, “I, (full name, military serial
number, and Social Security Number), hereby waive my
military retired pay for FERS retirement purposes, effective
close of business (specify the day before annuity begins).”
If you wish, add “I authorize the Office of Personnel
Management to withhold from my 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.
If you have already waived military retired pay in order
to receive credit for your active military service for FERS
retirement purposes, attach a copy of your request for
waiver and of any reply you have received.

If you have applied for or received workers’ compensation
from the Office of Workers’ Compensation Programs
(OWCP), U.S. Department of Labor, because of a job-related
illness or injury, check the “Yes” box and furnish your claim
number(s), type(s) of benefits, and date(s) of benefits in 3a,
3b and 3c.
The information requested regarding benefits from the
OWCP is needed because the law prohibits payment of
both FERS 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.

Section E - Marital Information
Item 2:

Indicate whether you have a living former spouse to whom a
court order awards a survivor annuity based on your Federal
employment. If you answer “Yes,” you must submit a copy
of the divorce decree and any attachments or amendments.

Section F - Annuity Election
Read the information about survivor benefits and their associated cost
found in the pamphlet “Applying for Deferred or Postponed Retirement
Under the Federal Employees Retirement System” (RI 92-19A) before
completing Section F.
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 or be a
parent of your child. The marriage duration requirement does not apply
if your death is accidental.
Survivor elections terminate upon the death of the person elected,
divorce of the annuitant from the elected spouse, remarriage of a former
spouse before age 55 (unless the parties were married for 30 years or
more), or subject to the terms of a court order acceptable for processing.
You must notify us when one of these events occurs. Please note that,
in accordance with the law, both a survivor annuity election made at
retirement and pre-divorce survivor annuity election terminate upon
death or divorce and the annuitant must make a new election (reelection) within 2 years after the terminating event to provide a survivor
annuity for a spouse acquired after retirement or for a former spouse.
Continuing a survivor reduction, by itself, is not effective to reelect a
survivor annuity for a spouse married after retirement or for a former
spouse.
Item 4:

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. Enter the requested information
about that person. Insurable interest exists if the person
named (such as a close relative) may reasonably expect to
derive financial benefit from your continued life.
You must provide documentation that you are in good
health in order to choose this type of annuity. You will be
notified of the additional evidence required.
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 following table.
The survivor’s rate will be 55% of your reduced annuity.

Age of the 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%

You may elect this insurable interest survivor annuity in
addition to a regular survivor annuity for a current or former
spouse. However, if you elect an insurable interest annuity
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 for 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 survivor
annuity and OPM is notified.
Item 5:

If you initial box 5, your former spouse(s) will receive a
survivor annuity upon your death. The maximum survivor
annuity payable to your former spouse(s) is 50% of your
unreduced annuity. Your annuity will be reduced 5% or
10% according to the total benefit you want to provide.
If you are married and initial box 5, you must complete and
attach Schedule A - Spouse’s Consent to Survivor Election,
to your application. The law requires consent of the spouse
if a married person elects less than the maximum survivor
benefit. You may not elect a combined benefit for your
current and former spouse(s) which exceeds 50% of your
benefit.

Section G - Information About Children
Complete Section G by providing the names and dates of birth of your
unmarried dependent children under the age of 18. Also list any child
over the age of 18 who is incapable of self-support because of mental
or physical disability incurred before the age of 18. Check the box
headed “disabled” by the name of each child to whom this applies.
Information about your children in your annuity claim file may help
to expedite the processing of claims for survivor benefits when you
die.

Section H - Direct Deposit
Complete in all cases. 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.
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
continue to receive your payment by check. If your permanent address
for receiving payments is outside the United States in a country not
accessible via direct deposit, you cannot currently be paid by direct
deposit.
Item 2:

You may obtain your Financial Institution Routing Number
by calling your bank, credit union, or savings institution.
This number is very important. We cannot pay by direct
deposit without it. We suggest you call your financial
institution to verify this number.

If you prefer, you may attach a cancelled personal check that shows
the information requested instead of filling in the requested financial
institution information. If you attach your personal check, it is
especially important that you contact your bank, credit union, or
savings institution to confirm that the information on the check is
correct information for direct deposit. (Some financial institutions,
especially credit unions, use different routing numbers on checks.)
We can then use this information to start paying you by direct deposit.

Section I - Applicant’s Certification
Be sure to sign (do not print) and date your application after
reviewing the warning.

Schedules (Attachments)
There are three schedules attached to this application for deferred or
postponed retirement. Some of these schedules may apply to you and
some may not. Read the following to determine which schedules you
should complete. Instructions for completing and information about
each follows.

Schedule A - Spouse’s Consent to Survivor Election
Complete this schedule if you are married and, in Section F, you do
not elect box 1, a maximum survivor annuity for your spouse. For
any other election you must obtain your spouse’s consent. (See
the pamphlet entitled “Applying for A Deferred or Postponed
Retirement Benefit Under the Federal Employees Retirement System”
(RI 92-19A) for information about asking the Office of Personnel
Management (OPM) to waive the spousal consent requirement in
special circumstances.)
Part 1:

You must complete this section. Include your name, date
of birth and social security number as shown on your
application. Check the box that corresponds to the selection
you made in Section F on your application.

Part 2:

Your spouse completes this section, in the presence of a
notary public.

Part 3:

A notary public or other person authorized to
administer oaths (e.g., a justice of the peace) must complete
this section, after witnessing your spouse’s signature.

Your annuity will be reduced by 5/12 of 1% for
each full month (5% per year) that the date your
annuity begins precedes your 62nd birthday. You
can avoid the age reduction entirely if you choose
the first day of the month that you reach age 62 as
your annuity commencing date. The age reduction
does not apply if:

Schedules B & C - For Applicants Who Have At Least 10
Years of Creditable Service
If you have at least 10 years of creditable service (5 of which must be
civilian) which will be used to compute your benefit, then you must
complete one of these two schedules. Do not complete either of these
schedules if you have less than 10 years of service.
Complete Schedule B if you were the Minimum Retirement Age
(MRA) when you left Federal service and had at least 10 years of
creditable service. You are eligible to choose when you want your
benefit to begin and may be eligible to reenroll in the health benefits
and life insurance programs and carry them into retirement.

55 years, 2 months

1949

55 years, 4 months

1950

55 years, 6 months

1951

55 years, 8 months

1952

55 years, 10 months

1953 to 1964

If you are enrolled in the Federal Long Term Care Insurance
Program (FLTCIP), your coverage will continue. No action
is required by you. However, you may choose to have your
premium payments deducted from your annuity. To elect
annuity deduction of premiums, please call Long Term Care
Partners, at 1-800-582-3337 (TTY: 1-800-843-3557).

56 years

1965

56 years, 2 months

1966

56 years, 4 months

1967

56 years, 6 months

1968

56 years, 8 months

1969

56 years, 10 months

After 1969

Your annuity commences the first day of the
month after you reach your MRA and you have
at least 30 years of service.

Part 5:

Your MRA is:
55 years

1948

b)

People who leave Federal service after reaching the MRA
with at least 10 years of creditable Federal service are
eligible to reenroll in the Federal Employees Health Benefits
Program and the Federal Employees’ Group Life Insurance
Program if they had participated in the program for the 5
years of service immediately before their separation date or
continually from their earliest opportunity. If you were
enrolled in either of these programs when you left Federal
employment and you had already attained your MRA and
had 10 years of creditable service, complete these sections.
If you want information about reenrolling in either program,
indicate so in item 1b.

The MRA is based on the year of your birth and determines the earliest
date you became eligible to have your retirement annuity begin. The
Minimum Retirement Age Schedule is:

Before 1948

Your annuity commences the first day of the
month after your 60th birthday and you have
at least 20 years of service, or

Parts 3
and 4:

Complete Schedule C if you were not yet the MRA when you left
Federal service, but you did have at least 10 years of creditable service.
You are eligible to choose when you want your benefit to begin.

If your year of birth is:

a)

If you are not currently enrolled in the FLTCIP, you, your
spouse, and your adult children may apply for FLTCIP
coverage provided you are eligible for a deferred or
postponed annuity. You may request an application by
calling Long Term Care Partners, at 1-800-582-3337
(TTY: 1-800-843-3557), or by visiting www.ltcfeds.com.

57 years

Schedule C
Part 2:

Schedule B
Part 2:

You may choose to have your annuity begin on:
1.
2.

the first day of the month following your separation
from Federal service; or
The first day of any month which is at least 31 days
after the Office of Personnel Management (OPM)
receives your application for retirement (but before
your 62nd birthday).

You may choose to have your annuity begin on:
1.

the first day of the month following the month in
which you reach your MRA; or

2.

the first day of any month which is at least 31 days
after OPM receives your application for retirement
if you have reached your MRA (but before your
62nd birthday).

Your annuity will be reduced by 5/12 of 1% for each full
month (5% per year) that the date your annuity begins
precedes your 62nd birthday. You can avoid the age
reduction entirely if you choose the first day of the month
that you reach age 62 as your annuity commencing date.
The age reduction does not apply if:
a)

Your annuity commences the first day of the month
after your 60th birthday and you have at least 20
years of service, or

b)

Your annuity commences the first day of the month
after you reach your MRA and you have at least 30
years of service.

Part 3:

If you are enrolled in the Federal Long Term Care Insurance
Program (FLTCIP), your coverage will continue. No action
is required by you. However, you may choose to have your
premium payments deducted from your annuity. To elect
annuity deduction of premiums, please call Long Term Care
Partners, at 1-800-582-3337 (TTY: 1-800-843-3557).
If you are not currently enrolled in the FLTCIP, you, your
spouse, and your adult children may apply for FLTCIP
coverage provided you are eligible for a deferred or
postponed annuity. You may request an application by
calling Long Term Care Partners, at 1-800-582-3337
(TTY: 1-800-843-3557), or by visiting www.ltcfeds.com.

Privacy Act and Public Burden Statement
Solicitation of this information is authorized by the Federal Employees Retirement System law (Chapter 84, title 5, U.S. Code). 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 those programs. It may also be shared and verified, as noted above, with law
enforcement agencies when they are investigating a violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes
use of the Social Security Number as an individual identifier to distinguish between people with the same or similar names. Failure to furnish
the requested data may delay or prevent action on the retirement application.

We estimate that this form takes an average of 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 (OPM), Retirement Services Publications Team
(3206-0190), Washington, D.C. 20415-3430. The OMB number, 3206-0190, is currently valid. OPM may not collect this information,
and you are not required to respond, unless this number is displayed.

Form Approved:
OMB No. 3206-0190

Application for Deferred or Postponed Retirement
Federal Employees Retirement System

Federal Employees
Retirement System

Section A - Identifying Information
3.

Date of birth (mm/dd/yyyy)

1.

Name (Last, first, middle)

2.

4.

Address (Number, street, city, state, ZIP Code)

5a. Daytime telephone number

5b. Best time to reach you

6.

Email address

7.

8.

Are you a citizen of the United States of America?

List all other names used

Social Security Number

Yes

No

Section B - Federal Civilian Service
1.

Date on which you separated from Federal service (mm/dd/yyyy)

3.

List below all Federal service you have performed.
Department or Agency, including Bureau or Division

2.

What agency did you separate from? (Give agency, group or office)

Location (City and state)

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

Section C - Military Service
1.

Have you performed active, honorable service in the Armed Forces or other uniformed services of the United States? (See instructions for definition.)

2.

If you have military service performed after 1956, did you pay a deposit to your former employing agency?

Yes, go to item 2.

No, go to Section D.

Not applicable, go to item 3.

Yes, go to item 2a.

2a. When did you pay your deposit for post-56 military service? (mm/dd/yyyy)

3.

If you have performed active, honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definition), complete 3a-d
below and attach a copy of your discharge certificate or other certificate of active military service (if available).
3a. Branch of Service

4.

No, go to item 3.

2b. To which agency did you make the payment? (Give agency, bureau or division and
location)

3b. Serial Number

Are you receiving or have you ever applied for military retired or retainer
pay (including disability retired pay)?

Yes, complete items 4a-4c.
No, go to Section D.
4b. Was your military retired or retainer pay awarded for reserve service
under Chapter 1223, Title 10 [formerly Chapter 67, title 10]?

Yes, if available, please attach a copy of notice of award.
No

Office of Personnel Management
CSRS/FERS Handbook
Previous edition is not usable

3c. Dates of Active Duty
From (mm/dd/yyyy)

To (mm/dd/yyyy)

3d. Last Grade or Rank

4a. Was your military retired or retainer pay awarded for disability incurred in combat or
caused by an instrumentality of war and incurred in the line of duty during a period
of war?

Yes, if available, attach a copy of notice of award.
No
4c. Are you waiving your military retired pay in order to receive credit for FERS?

Yes, see instructions for information about how to request a waiver.
Yes, a copy of my waiver is attached.
No

Continued on reverse

RI 92-19
Revised June 2008

Section D - Other Claim Information
1.

Have you previously filed any application under the Federal Employees Retirement System or Civil Service Retirement System (for refund, retirement, deposit,
redeposit, etc) ?

Yes (Compete items 1a and 1b)

No
1b. Claim number(s)

1a. Type of application

Retirement
Refund
2.

Deposit/redeposit
Refund of excess deductions

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

Yes (Complete below)

No
2b. Dates of Service

2a. Name of other
Retirement System

3.

2c. Location of
Employment

From (mm/dd/yyyy) To (mm/dd/yyyy)

2d. Title of Position

2e. Were retirement
deductions withheld?
Refunded
Yes
No

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

Yes, complete 3a thru 3c.
3a. Compensation Claim Number

No

3b Description of benefit

Scheduled Award

Total/partial disability

3c. Date benefits
received

From (mm/dd/yyyy) To (mm/dd/yyyy)

Section E - Marital Information
1.

Are you married? If separated from your spouse, but the marriage has not ended by divorce or annulment, answer "Yes."

Yes (Complete items 1a thru 1f.)

No

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

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

1d. Place of marriage (City, state)

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

Statement regarding
Former Spouses

2.

1f. Marriage
performed by

Clergyman or Justice of the Peace
Other (Explain)

Do you have a living former spouse(s) to whom a court order gives a survivor annuity?

No

Yes

Section F - Annuity Election
Read the attached instructions before making this 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 granted except as explained in the pamphlet Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement System,
RI 92-19A. 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 Schedule A and attach it to this application. If you are married, you must initial box 1, 2, or 3. If you are married and initial box 3, you may also initial box 4. If you are
married and initial box 2 or 3, you may also initial box 5, as well as box 4.
Your election to provide a survivor annuity for a current spouse terminates upon the death of that spouse or if the marriage ends due to divorce or annulment. If you wish to reelect
a survivor annuity for a former spouse, you are required to make a new election (reelect) within 2 years of the event that terminated the survivor annuity. If you wish to elect a
survivor annuity for a spouse you marry after retirement, you are required to make an election within 2 years of the marriage.
1. I choose a reduced annuity with maximum survivor annuity for my spouse named in Section E.
Initials

2.

I choose a reduced annuity with a partial survivor annuity for my spouse named in Section E.
Initials

3.

If you choose this option, your annuity will be reduced by 5%. Upon your death, your spouse's annuity will be 25% of your unreduced
annuity. You must have your spouse's consent to choose this option. Attach Schedule A showing your spouse's consent.

I choose an annuity payable only during my lifetime.

Initials

4.

If you are married at retirement you will automatically receive this type of annuity unless your spouse consents to your election not to
provide maximum survivor benefits. If you receive this annuity, your annuity will be reduced by 10%. The survivor's annuity upon your
death will be 50% of your unreduced annuity.

No current spouse survivor annuity will be paid to your spouse after your death if he or she consents to this election. If you are married
at retirement, you cannot choose this type of annuity without your spouse's consent. You should initial this box if you are electing an
insurable interest benefit (Box 4) for your current spouse. Attach Schedule A showing your spouse's consent. If you are eligible to
continue your health benefits coverage into retirement, your spouse's health benefits coverage will terminate upon your death. In
addition,your spouse will not be eligible to enroll in the Federal Long Term Care Insurance program, if he/she is not enrolled at the time
of your death.

I choose a reduced annuity with survivor annuity for the person named below who has an insurable interest in me.
Initials

You must be healthy and willing to provide medical evidence if you choose this type of annuity.

Name of person with insurable interest

Office of Personnel Management
CSRS/FERS Handbook
Previous edition is not usable

Relationship to you

Date of birth (mm/dd/yyyy)

Social Security Number

Reverse of Page 1
RI 92-19
Revised June 2008

5.

I choose a reduced annuity with survivor annuity for my former spouse(s) as follows:
Initials

You must attach:

1.
2.

Certified copies of divorce decrees for all former spouses for whom you elect to provide survivor annuity.
If you are married, attach a completed Schedule A (Spouse's Consent to Survivor Election). You cannot
choose this option and provide a maximum survivor annuity for your spouse (Box 1).

Your election to provide a survivor annuity for a former spouse terminates upon the death of that spouse or the remarriage of your
former spouse before age 55.
This election when combined with an election in Box 2 cannot exceed 50% of your unreduced annuity.
Persons who completed Box 1 may not complete Box 5.
Name and address of former spouse

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

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 this
percent of my annuity

%
Survivor annuity equal to this
percent of my annuity

%

Total (Must equal either 25% or 50%)

0

%

Section G - Information About Your Unmarried Dependent Children
Dependent Child's Name
(First, middle, last)

Date of Birth
(mm/dd/yyyy)

Disabled

[

Dependent Child's Name
(First,middle,last)

Date of Birth
(mm/dd/yyyy)

Disabled

[

Section H - 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 continue to 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 me my payment(s) by
check. (Go to Section I)
My permanent payment address is outside the United States in a country not accessible via direct deposit. (Go to Section I)
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 I - Applicant's Certification
Warning

I hereby certify that all statements made in this application are true to the best of my knowledge and that no evidence
Any intentionally false statement in this application necessary to the settlement of this claim is withheld. I have read and understand all the information provided in the
or willfully misleading statement or response you instructions to this application.
provide in this application is a violation of the law
Signature (Do not print)
Date (mm/dd/yyyy)
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).
Office of Personnel Management
CSRS/FERS Handbook
Previous edition is not usable

Page 2
RI 92-19
Revised June 2008

Schedule A - Spouse's Consent to Survivor Election
Instructions - Complete this schedule if you are married and do not elect a reduced annuity to provide a full current spouse survivor
annuity. Complete Part 1. 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 box which describes the election you have made with regard to your current spouse.)

A.

No regular or insurable interest survivor annuity for my current spouse. I understand that:
!
No survivor annuity will be paid to my spouse after my death.
!

If I am eligible to continue my health benefits coverage into retirement, his/her health benefits coverage will terminate upon my death, and

!

He/she will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) after my death.

B.

A partial survivor annuity for my current spouse equal to 25% of my annuity.

C.

I am electing an insurable interest survivor annuity for my current spouse, but no regular survivor annuity for my current spouse.
(I have completed Section F, Box 4, on my RI 92-19, naming my current spouse.)

Part 2 - To Be Completed By Current Spouse of Applicant
I freely consent to the survivor annuity election described in Part 1. I understand that my consent is final (not revocable).

Signature (Do not print)

Name (Type or print)

Date (mm/dd/yyyy)

Part 3 - To Be Completed By a Notary Public or
Other Person Authorized to Administer Oaths
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 ______________________________________, ____________
(Month)
(Year)
at ____________________________________________________________________________________________ .
(City, state)
Signature (Do not print)

Seal
Expiration date of Commission, if Notary Public (mm/dd/yyyy)

General Information

Public Law 99-335 requires that a person who is married at the time his or her retirement annuity begins must elect to provide a full survivor annuity for a
current spouse, unless the current spouse consents to some other election by signing this form.
A court order which requires an annuitant 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 retiring employee can still elect to provide a survivor
annuity for the current spouse even though the Office of Personnel Management (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 the terms of the court order, remarriage before age 55, or death).
Privacy Act and Public Burden Statement

Public Law 99-335, which established the spousal consent requirement for FERS, 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 those programs. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a 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 data will
delay or prevent action on the retirement application.
We estimate that this form takes an average of 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 (OPM), Retirement Services Publications Team (3206-0190), Washington, D.C. 20415-3430. The OMB
number, 3206-0190, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Office of Personnel Management
CSRS/FERS Handbook
Previous edition is not usable

RI 92-19
Revised June 2008

Schedule B - For Applicants with Immediate MRA+10 Eligibility
(who may choose to postpone)

To be completed only by applicants who were eligible for an immediate MRA+10 annuity based on having reached the Minimum
Retirement Age and having at least 10 years of creditable service at separation. Read instructions carefully to determine if you
should complete this schedule.

Part 1 - Identifying Information
Date of birth (mm/dd/yyyy)

Name (Last, first, middle)

Social Security Number

Part 2 - Commencing Date
I want my benefit to begin accruing (mm/dd/yyyy)

Read the instructions carefully and
elect when you want your benefits to begin.

Part 3 - Health Benefits Coverage
1.

When you separated from service, were you enrolled (or covered as a family member) in the Federal Employees Health Benefits Program?

No, go to Part 4.

Yes, complete items 1a-1c.
1a.

What plan were you enrolled in when you separated (if known)?

1b.

Do you want information on reenrolling with the
Federal Employees Health Benefits Program?

Plan Name

Yes
No

Enrollment Code

Yes, attach copy.
No

1c. Do you have a copy of your SF 2810
terminating your enrollment?

Part 4 - Life Insurance Coverages
1. When you separated from service, were you enrolled in the Federal Employees' Group Life Insurance Program?
Yes (Also complete items 1a-1d).

No, go to Part 5.

1a. What coverage(s) did you have when you separated?

1b. Do you want information on starting
your coverage(s) again?
Option B -- Additional _________# of multiples (if known)
Basic
Option A -- Standard
Yes
No
Option C -- Family __________# of multiples (if known)
1c. Did you convert your coverage(s) to a private plan?
1d. Do you have a copy of your SF 2821 terminating your coverage(s)?

No

Yes

Yes, attach copy.

No

Part 5 - Long Term Care Insurance Coverage
1. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?
Yes. Your coverage will continue. If you want your premium payments
deducted from your annuity, call the FLTCIP administrator, Long Term Care
Partners, at 1-800-582-3337.

No. If you are not currently enrolled in the Federal Long Term Care
Insurance Program, you, your spouse, and your adult children may apply for
coverage provided you are eligible for a deferred or postponed annuity. You
may request an application by contacting Long Term Care Partners, at
1-800-582-3337.

Part 6 - Applicant's Signature
Signature

Date (mm/dd/yyyy)

Schedule C - For Applicants with Deferred MRA+10 Eligibility
(who may choose to postpone)

To be completed only by applicants eligible for a deferred (non-immediate) annuity based on at least 10 years of creditable service.
Read the instructions carefully to determine if you should complete this Schedule.

Part 1 - Identifying Information
Name (Last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

Part 2 - Commencing Date
Read the instructions carefully and
elect when you want your benefits to begin.

I want my benefit to begin accruing (mm/dd/yyyy)

Part 3 - Long Term Care Insurance Coverage
1. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?
Yes. Your coverage will continue. If you want your premium payments
deducted from your annuity, call the FLTCIP administrator, Long Term Care
Partners, at 1-800-582-3337.

No. If you are not currently enrolled in the Federal Long Term Care
Insurance Program, you, your spouse, and your adult children may apply for
coverage provided you are eligible for a deferred or postponed annuity. You
may request an application by contacting Long Term Care Partners, at
1-800-582-3337.

Part 4 - Applicant's Signature
Signature

Office of Personnel Management
Previous edition is not usable

Date (mm/dd/yyyy)

CSRS/FERS Handbook

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RI 92-19
Revised June 2008