RI 20-120 July 2012 Markup

Form approved:
OMB No.: 3206-0245

Claim number

CSA
U.S. Office of Personnel Management
Retirement Operations Center
Post Retirement
Attention: Y-Adjustment
P.O. Box 45
Boyers, PA 16017-0045

Request for Change to Unreduced Annuity
In order to change my benefit to the unreduced annuity rate, I am providing the
information below.
The reason my marriage ended is:

Spouse Died

Divorce

Annulment

The date my marriage ended is: ______________________________________________
I have enclosed: (Check one block below.)
A copy of the death certificate.
A court-certified copy of my divorce decree, including all property settlements.
A court-certified copy of my annulment.
I understand that if I have self and family health benefits coverage, I can change to selfonly at any time.
Change my coverage to self-only.
(Note: Check this block if you want to make the change. A former spouse is no longer a
family member and is not eligible for coverage under your family enrollment.)
Signature (do not print)

Date (dd/mm/yyyy)

Name (last, first, middle initial)

Email address

Telephone no. (include area code)

Public Burden Statement

We estimate this form takes an average of 30 minutes per response to complete. 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 (3206-0245), Washington, D.C. 20415-3430. The OMB number 3206-0245 is currently valid. OPM may
not collect this information, and you are not required to respond, unless this number is displayed.
RI 20-120
Revised July 2012
Previous editions are not usable.