RI 20-120 Sept 06 Markup

Form approved:
OMB No.: 3206-0245

Claim number
CSA

U.S. Office of Personnel Management
Retirement Services and Management Group
Text Added
P.O. Box 45
Boyers, PA 16017-0045
Attention: Y-Adjustment

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 self-only 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)
Name (last, first, middle initial)

Date

Email Address Field added

Telephone number including 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, CRIS 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.

Previous editions are not usable.

RI 20-120
Revised September 2006