RI 34-003 December 2012 Markup

Form Approved:
OMB No. 3206-0167

United States
Office of Personnel Management
Retirement Operations
Washington, D.C. 20415

Part 1
Notice of Amount Due Because
Of Annuity Overpayment

A COLLECTION IS SCHEDULED FROM YOUR ANNUITY BECAUSE YOU HAVE BEEN OVERPAID. Based on the explanation shown in box
9 below, the Office of Personnel Management (OPM) has determined that you were paid more annuity than you were entitled to receive under the Civil
Service Retirement System (CSRS) or the Federal Employees Retirement System (FERS). This excess payment is an amount you owe and we intend to
collect it by offset from your annuity. The total amount is shown in box 5 below and the proposed collection schedule is shown in boxes 6 and 7.
1. Retirement claim number

•
2. Case name
3. This notice dated
4. To request reconsideration/waiver, reply by
5. Total to be collected

6. First installment to be collected from payment dated

Collection
Schedule
Period during which the overpayment accrued

7. Number of installments

_________________ installments of $
and
a final installment of $
8a. From

8b. To

9. Cause of overpayment:

If you wish to make payment in full, see Part 2.

Your Rights Concerning This Overpayment
Before we can begin collection, we must tell you about your rights.
You or an individual you have authorized in writing to represent you may
personally inspect and copy our records pertaining to the overpayment at
our office in Washington, DC. Alternatively, you or your representative
may ask for a copy of our records. You must request an appointment for
personal inspection or a copy of the pertinent records on Part 2 of this
form.
A. INSTALLMENTS COLLECTED AS SHOWN ABOVE OR
PAYMENT IN FULL (INSTRUCTIONS FOR PART 2A OF THIS
FORM) - If you accept our decision concerning the existence and amount
of the overpayment, and agree to the installment withholding schedule
shown in blocks 6 and 7, you do not need to take any action. Payments
will automatically be deducted from your annuity as shown.
If you accept our decision concerning the existence and amount of the
overpayment, but do not want to pay in installments, you may check box
1 or 2 on Part 2 of this form and make payment in full as indicated.
1. Full Payment - Enclosed (Check box 1 on Part 2 of this form)
2. Full Payment Within 90 Days (Check box 2 on Part 2) - We will
allow a maximum of 90 days to make full payment. You should specify
the date when payment will be mailed in the space provided. If payment
has not been received within 30 days after the date you specify, we will
begin installment deductions as indicated in blocks 6 and 7 on Part 1 of
this form.
B. LOWER
INSTALLMENTS
OR
COMPROMISE
(INSTRUCTIONS FOR PART 2B OF THIS FORM) - If you accept
our decision concerning the existence and the amount of the overpayment,
but want to request lower installments or make a compromise payment
offer, check the appropriate box in Part 2B and submit any supporting
documents or statements requested.

3. Lower Installments (Check box 3 on Part 2) - You can ask OPM to
increase or decrease the amount of the installment we plan to deduct
(block 7 on Part 1 of this form) from your annuity. If you ask that the
installments be decreased, you must also indicate the amount you think
you can pay monthly. Also, complete the enclosed Financial Resources
Questionnaire to show that lower installments are necessary. (Note: You
do not need to fill out the Financial Resources Questionnaire to request
lower installments as long as your payments are at least $50 a month and
are sufficient to pay off the entire amount within 3 years.) We will do our
best to accommodate your financial situation. However, we cannot
guarantee that the amount you specify will be approved.
4. Compromise (Check box 4 on Part 2 of this form) - Based on the
evaluation of your Financial Resources Questionnaire, if we determine
that you cannot repay the full amount within a reasonable period of time,
we may suggest a compromise. A compromise, in most instances, will
involve our acceptance of less than the total amount as full settlement for
our claim. (See 4 CFR 103.1, et seq.)
You can suggest a compromise of your own. We prefer that such offers
not involve installment payments. Rather, your compromise offer could
be, for example, an offer to pay a smaller lump sum now in full settlement
of an overpayment we set up for recovery over a period of months.
We will consider compromise offers involving installment payments.
However, you must be willing to sign a firm written offer of compromise.
Your offer of compromise must be for a specific dollar amount with a
specific repayment schedule. In order to have your compromise offer
considered, state in the space provided on the back of Part 2 all the
reasons why you believe compromise would be appropriate given your
circumstances, and complete the Financial Resources Questionnaire. You
must establish your eligibility for compromise by substantial evidence.
(Note: We consider substantial evidence to be sufficient relevant evidence
supporting your conclusion to make a reasonable person decide in your
favor.)

Part 1 - For your records
Previous editions are usable

RI 34-3
Revised December 2012

C. RECONSIDERATION, WAIVER, LOWER INSTALLMENTS,
COMPROMISE, OR VOLUNTARY REPAYMENT AGREEMENT
(INSTRUCTIONS FOR PART 2C OF THIS FORM) - If you do not
accept our decision on the existence and/or amount of the overpayment,
you may request any of the options described below. You may request
more than one option. You should check the appropriate box in Part 2C of
this form and submit the supporting documents and statements requested.
If we determine that the decision on the existence and/or amount of the
overpayment is correct or we deny your request for a waiver, you have
the right to appeal our decision to the United States Merit Systems
Protection Board.
5. Reconsideration (Check box 5 on Part 2 of this form) - You can
request reconsideration of our decision that you owe us or that the amount
you owe equals the amount shown in box 5 above. Show in the space
provided on the back of Part 2, all the reasons you believe that you do not
owe us or that the amount is incorrectly computed. (See 5 CFR 831.1304
for CSRS annuitants or 5 CFR 845.204 for FERS annuitants.)
6. Waiver (Check box 6 on part 2 of this form) - Your request that OPM
waive (i.e., excuse repayment of) the overpayment collection must be
submitted by the date shown in block 4 at the top of this notice. You must
prove by substantial evidence that (1) you were not at fault and (2)
recovery of the overpayment would be against equity and good
conscience. (See 5 CFR 831, Subparts M and N for CSRS annuitants or 5
CFR 845 Subpart C for FERS annuitants.)
•

Fault - To support your waiver request, you must provide substantial
evidence that your action (or failure to take a necessary and timely
action) did not play a part in causing or increasing the overpayment.
In making our decision, we will look at the issues explained below in
light of such mitigating factors as your age, physical or mental
condition, the nature of the information supplied to you regarding the
circumstances leading to the overpayment, etc. (Note: By itself, the
fact that OPM may have been responsible for the overpayment does
not necessarily mean that you will be excused from making
repayment. See "Equity and Good Conscience.")

•

Considerations in Finding Fault - If you are submitting a request for
waiver, make sure you respond specifically to any of the questions
below that may apply to your overpayment:
a) If the overpayment occurred because of incorrect information you
furnished, would a reasonable person in your circumstances know
that the information was incorrect?
b) If the overpayment occurred because of your failure to provide
material information in your possession, would a reasonable
person in your circumstances know that he or she had to provide
the information and that failure to do so would make a difference
in the annuity paid?
c) If OPM made the error in your payment, should a reasonable person in your circumstances have known the payment was wrong?
• Equity and Good Conscience - Your submission in support of your
waiver request must provide substantial evidence to establish one or
more of the following:
a) Recovery of the overpayment would cause you financial hardship.
We will find that financial hardship exists to a degree that will
entitle you to a waiver if you can show on your Financial
Resources Questionnaire that you need substantially all of your
current income and liquid assets to meet ordinary and necessary
living expenses and liabilities. Note: 1) In making this decision,
we are primarily concerned with your ability to repay us now.
However, we will also consider whether your financial condition
can be expected to improve in the future. 2) If the expenses shown
on the Financial Resources Questionnaire include those of your
spouse and children, the income section must also include the
income generated by those members of your family.
b) When you received your overpayment, did it (regardless of your
current ability to repay) cause you to give up a valuable right, such
as some other benefit payment. Or, in reliance on the incorrect
payment, did you change your financial position for the worse,
such as making a commitment that you would not have made
under other circumstances.
Reverse of Part 1

c) Recovery of the overpayment would otherwise be inequitable due
to special or exceptional circumstances. Note: In the event we
determine that the overpayment exists, the amount owed is correct,
and your waiver or compromise request is denied, we may still
consider lessening the financial burden by lowering your monthly
installments. For this pupose, you should indicate on Part 2 of this
form the amount you can repay on a monthly basis to pay in full.
7. Lower Installments Or A Compromise Payment (Check the
appropriate box in item 7 on Part 2 of this form) - In the event your
reconsideration or waiver request is denied, you may also request lower
installments or offer a compromise payment. Make, on the back of Part 2,
the statements required to support your request (see the discussion of
"Lower Installments" and "Compromise" on the reverse), and complete
the Financial Resources Questionnaire.
8. VOLUNTARY REPAYMENT AGREEMENT (Check box 8 on
Part 2 of this form) - Rather than having your annuity offset, you may ask
us to let you send in regular installment payments. We have sole
discretion whether to accept such payments in place of the offset. If you
want to send your payments to us instead of having them deducted from
your annuity, you must complete Part 2 of this form. In the space titled
"Your Statement Concerning the Overpayment" show that deducting
monthly installments from your annuity would cause a financial hardship
or would be against equity and good conscience. You must also complete
the Financial Resources Questionnaire. Do not make payments until we
notify you that the voluntary repayment agreement is acceptable. If we
approve the voluntary repayment agreement and your account becomes
delinquent, we will cancel the repayment agreement and make deductions
from your annuity until the amount is paid.
D. HOW AND WHEN TO MAKE YOUR REQUEST - The
procedures for requesting copies of your records, lower installments, a
voluntary repayment agreement, reconsideration, waiver, or compromise
are as follows:
1. Complete Part 2 of this form and state your reasons for making the
request(s). If your name and address as shown are not correct, make
any necessary changes.
2. If your request is returned to us by mail, it must be postmarked within
30 calendar days after the date of this notice (see box 3) and mailed to:
Office of Personnel Management
Attn: Funds Management
P.O. Box 7125
Washington, DC 20044-7125
3. If you hand deliver your request, bring it to:
Office of Personnel Management
Retirement Information Office
1900 E Street, NW - Room 1323B
Washington, DC
4. OPM can extend the 30-day time limit only if you show that you were
not aware of the time limit or you were prevented from responding by
a cause beyond your control.
If you plan to submit additional evidence to support your request and that
information is not available, you must:
• Submit Part 2 of this form within the 30-day time limit; and
• Include in your request a statement that you will be submitting
additional evidence, a brief description of the evidence that you will
submit, your estimate of the date the evidence will be available, and a
brief explanation for the delay.
We will acknowledge receipt of your statement and consider your request
filed on time. Please send the additional evidence as soon as possible.
E. FINAL DECISION - After we consider your request, we will send
you a final decision in writing. If our decision is not in your favor, any
further rights of review available to you will be explained at that time.
Collection actions will be suspended at all levels of review if a timely
request is received, unless you become eligible for a lump sum payment
or your recurring monthly payment is scheduled to cease within one year
and (1) failure to make offset would substantially prejudice the
Government's ability to collect and (2) the time before the payment is to
be made does not permit completion of the proceedings explained above.
RI 34-3
Revised December 2012

Form Approved:
OMB No. 3206-0167

United States
Office of Personnel Management
Retirement Operations
Washington, D.C. 20415

Part 2
Request for Lower Installments, Voluntary Repayment
Agreement, Reconsideration, Waiver, And/Or Compromise
When An Overpayment Was Made From The Civil Service
Retirement and Disability Fund

1. Retirement claim number

•
2. Case name
3. This notice dated
4. To request reconsideration/waiver, reply by
5. Total to be collected

6. First installment to be collected from payment dated

Collection
Schedule

7. Number of installments

_________________ installments of $
and
a final installment of $

Period during which the overpayment accrued

8a. From

8b. To

9. Cause of overpayment:

Check the box or boxes that apply to you. You may check more than one box, unless you check boxes A.1 or A.2.

A.

B.

I accept the decision on the existence and amount of the overpayment, and I agree to make payment in full. I will not make partial payments.
I agree to make -1.

Full Payment Enclosed

My check or money order, payable to the U.S. Office of Personnel Management in the amount of
$_______________________ is enclosed.

2.

Full Payment
Within 90 Days

I will send my check or money order payable to the U.S. Office of Personnel Management in the amount of
$________________________ on or before ______________________.

I accept the decision on the existence and amount of the overpayment, but I request -3.

Lower Installments

I request lower installments. I understand that OPM generally expects to be repaid within 36 months and that
each installment be at least $50 per month. I have indicated below the amount I can pay each month.
My financial resources will allow me to have $_____________ per month deducted from my annuity. I am
submitting the Financial Resources Questionnaire and my statement on the reverse to support my request.

C.

4.

Compromise

I propose a compromise payment. I have indicated the amount and terms of my offer on the reverse. I am
submitting the Financial Resources Questionnaire and my statement on the reverse to support my request. I
understand that I must establish by substantial evidence that I am unable to repay the full amount within a
reasonable time.
I do not accept your decision to recover this overpayment from my annuity and I request -5.

Reconsideration of the
Existence or Amount of
the Overpayment

I am providing the specific reasons for my disagreement with your decision on the reverse. If the existence
and/or the amount of the overpayment is confirmed, I understand that the money will be collected as shown in
block 7 above, unless my request for waiver, lower installments, or a compromise is approved.

6.

Waiver

I am submitting the Financial Resources Questionnaire (unless my waiver request is not based on financial
hardship) and my statement on the reverse to support my request. I understand that I must establish by
substantial evidence that I am eligible for a waiver.

7.

Lower Installments or a
Compromise Payment

If the existence and/or the amount of overpayment is confirmed or my waiver request is denied, I also request
consideration for
lower installments in the amount of $__________________ per month
a compromise
payment as shown on the reverse. (Please check the applicable box.) I am submitting the Financial Resources
Questionnaire and my statement on the reverse to support my request.

8.

Voluntary Repayment
Agreement

I am submitting the Financial Resources Questionnaire and my statement on the reverse to support my request.

Remember, in the event that we determine (1) the overpayment exists and the amount owed is correct and (2) your request for a voluntary repayment agreement, waiver, or compromise is denied, we
may consider alleviating the financial burden of repayment by lowering your monthly installments. Be sure to tell us what you can repay in your response to item C.7. above.

Part 2 - Use this form if you wish to request lower installments, a voluntary repayment agreement, reconsideration, waiver, or compromise.
RI 34-3
Revised December 2012

Your Statement Concerning The Overpayment
(Attach additional pages if necessary)

Your signature

Telephone number (including area code) Email Address

Date

Mail to:

Office of Personnel Management
Attn: Funds Management
P.O. Box 7125
Washington, DC 20044-7125

Privacy Act Statement
OPM administers the retirement systems for Federal employees and annuitants as
authorized by chapters 83, 84, 87, and 89 of title 5, U.S. Code and Public Laws
83-589, 84-356, and 86-724. The Federal Claims Collection Act of 1966 (Public
Law 89-508) empowers the head of a Federal agency to enforce collection of claims
of the United States for money or property arising out of the activities of the agency.
Section 179.102 of title 5, Code of Federal Regulations, delegates authority to the
Associate Director for Retirement and Insurance for collection of claims arising out
of overpayments of Federal retirement benefits. The information requested on this
form is needed to determine whether you qualify for the relief you are seeking.
Intentionally false statements and/or suspected illegal activities are reportable to the
appropriate law enforcement agencies. The information you provide may be shared
with the Government Accounting Office and the United States Department of Justice
in the event litigation is required to enforce collection.

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 in order to determine benefits
under their programs, to obtain information necessary for determination or continuation
of benefits under this program, or to report income for tax purposes. 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. Provision of the
information is voluntary; however, failure to supply all the requested information or
including intentionally false statements may result in an unfavorable decision or a
financial investigation of the person who owes the United States. Pending the results of
the investigation, evidence may be turned over to the Department of Justice for
appropriate action.

Public Burden Statement
We estimate this form takes an average of 60 minutes to complete, including the time for
reviewing instuctions, 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 United States Office of Personnel Management

Reverse of Part 2

(OPM), Retirement Services Publications Team (3206-0167),Washington, D.C.
20415-3430. The OMB Number, 3206-0167, is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number
is dispalyed.

RI 34-3
Revised December 2012

Form Approved:
OMB No. 3206-0167

United States
Office of Personnel Management
Retirement Operations
Washington, D.C. 20415

Part 1
Notice of Amount Due Because
Of Annuity Overpayment

A COLLECTION IS SCHEDULED FROM YOUR ANNUITY BECAUSE YOU HAVE BEEN OVERPAID. Based on the explanation shown in box
9 below, the Office of Personnel Management (OPM) has determined that you were paid more annuity than you were entitled to receive under the Civil
Service Retirement System (CSRS) or the Federal Employees Retirement System (FERS). This excess payment is an amount you owe and we intend to
collect it by offset from your annuity. The total amount is shown in box 5 below and the proposed collection schedule is shown in boxes 6 and 7.
1. Retirement claim number

•
2. Case name
3. This notice dated
4. To request reconsideration/waiver, reply by
5. Total to be collected

6. First installment to be collected from payment dated

Collection
Schedule
Period during which the overpayment accrued

7. Number of installments

_________________ installments of $
and
a final installment of $
8a. From

8b. To

9. Cause of overpayment:

If you wish to make payment in full, see Part 2.

Your Rights Concerning This Overpayment
Before we can begin collection, we must tell you about your rights.
You or an individual you have authorized in writing to represent you may
personally inspect and copy our records pertaining to the overpayment at
our office in Washington, DC. Alternatively, you or your representative
may ask for a copy of our records. You must request an appointment for
personal inspection or a copy of the pertinent records on Part 2 of this
form.
A. INSTALLMENTS COLLECTED AS SHOWN ABOVE OR
PAYMENT IN FULL (INSTRUCTIONS FOR PART 2A OF THIS
FORM) - If you accept our decision concerning the existence and amount
of the overpayment, and agree to the installment withholding schedule
shown in blocks 6 and 7, you do not need to take any action. Payments
will automatically be deducted from your annuity as shown.
If you accept our decision concerning the existence and amount of the
overpayment, but do not want to pay in installments, you may check box
1 or 2 on Part 2 of this form and make payment in full as indicated.
1. Full Payment - Enclosed (Check box 1 on Part 2 of this form)
2. Full Payment Within 90 Days (Check box 2 on Part 2) - We will
allow a maximum of 90 days to make full payment. You should specify
the date when payment will be mailed in the space provided. If payment
has not been received within 30 days after the date you specify, we will
begin installment deductions as indicated in blocks 6 and 7 on Part 1 of
this form.
B. LOWER
INSTALLMENTS
OR
COMPROMISE
(INSTRUCTIONS FOR PART 2B OF THIS FORM) - If you accept
our decision concerning the existence and the amount of the overpayment,
but want to request lower installments or make a compromise payment
offer, check the appropriate box in Part 2B and submit any supporting
documents or statements requested.

3. Lower Installments (Check box 3 on Part 2) - You can ask OPM to
increase or decrease the amount of the installment we plan to deduct
(block 7 on Part 1 of this form) from your annuity. If you ask that the
installments be decreased, you must also indicate the amount you think
you can pay monthly. Also, complete the enclosed Financial Resources
Questionnaire to show that lower installments are necessary. (Note: You
do not need to fill out the Financial Resources Questionnaire to request
lower installments as long as your payments are at least $50 a month and
are sufficient to pay off the entire amount within 3 years.) We will do our
best to accommodate your financial situation. However, we cannot
guarantee that the amount you specify will be approved.
4. Compromise (Check box 4 on Part 2 of this form) - Based on the
evaluation of your Financial Resources Questionnaire, if we determine
that you cannot repay the full amount within a reasonable period of time,
we may suggest a compromise. A compromise, in most instances, will
involve our acceptance of less than the total amount as full settlement for
our claim. (See 4 CFR 103.1, et seq.)
You can suggest a compromise of your own. We prefer that such offers
not involve installment payments. Rather, your compromise offer could
be, for example, an offer to pay a smaller lump sum now in full settlement
of an overpayment we set up for recovery over a period of months.
We will consider compromise offers involving installment payments.
However, you must be willing to sign a firm written offer of compromise.
Your offer of compromise must be for a specific dollar amount with a
specific repayment schedule. In order to have your compromise offer
considered, state in the space provided on the back of Part 2 all the
reasons why you believe compromise would be appropriate given your
circumstances, and complete the Financial Resources Questionnaire. You
must establish your eligibility for compromise by substantial evidence.
(Note: We consider substantial evidence to be sufficient relevant evidence
supporting your conclusion to make a reasonable person decide in your
favor.)

Part 3 - File Copy
Previous editions are usable

RI 34-3
Revised December 2012

C. RECONSIDERATION, WAIVER, LOWER INSTALLMENTS,
COMPROMISE, OR VOLUNTARY REPAYMENT AGREEMENT
(INSTRUCTIONS FOR PART 2C OF THIS FORM) - If you do not
accept our decision on the existence and/or amount of the overpayment,
you may request any of the options described below. You may request
more than one option. You should check the appropriate box in Part 2C of
this form and submit the supporting documents and statements requested.
If we determine that the decision on the existence and/or amount of the
overpayment is correct or we deny your request for a waiver, you have the
right to appeal our decision to the United States Merit Systems Protection
Board.
5. Reconsideration (Check box 5 on Part 2 of this form) - You can
request reconsideration of our decision that you owe us or that the amount
you owe equals the amount shown in box 5 above. Show in the space
provided on the back of Part 2, all the reasons you believe that you do not
owe us or that the amount is incorrectly computed. (See 5 CFR 831.1304
for CSRS annuitants or 5 CFR 845.204 for FERS annuitants.)
6. Waiver (Check box 6 on part 2 of this form) - Your request that OPM
waive (i.e., excuse repayment of) the overpayment collection must be
submitted by the date shown in block 4 at the top of this notice. You must
prove by substantial evidence that (1) you were not at fault and (2)
recovery of the overpayment would be against equity and good
conscience. (See 5 CFR 831, Subparts M and N for CSRS annuitants or 5
CFR 845 Subpart C for FERS annuitants.)
•

Fault - To support your waiver request, you must provide substantial
evidence that your action (or failure to take a necessary and timely
action) did not play a part in causing or increasing the overpayment.
In making our decision, we will look at the issues explained below in
light of such mitigating factors as your age, physical or mental
condition, the nature of the information supplied to you regarding the
circumstances leading to the overpayment, etc. (Note: By itself, the
fact that OPM may have been responsible for the overpayment does
not necessarily mean that you will be excused from making
repayment. See "Equity and Good Conscience.")

•

Considerations in Finding Fault - If you are submitting a request for
waiver, make sure you respond specifically to any of the questions
below that may apply to your overpayment:
a) If the overpayment occurred because of incorrect information you
furnished, would a reasonable person in your circumstances know
that the information was incorrect?
b) If the overpayment occurred because of your failure to provide
material information in your possession, would a reasonable
person in your circumstances know that he or she had to provide
the information and that failure to do so would make a difference
in the annuity paid?
c) If OPM made the error in your payment, should a reasonable person in your circumstances have known the payment was wrong?
• Equity and Good Conscience - Your submission in support of your
waiver request must provide substantial evidence to establish one or
more of the following:
a) Recovery of the overpayment would cause you financial hardship.
We will find that financial hardship exists to a degree that will
entitle you to a waiver if you can show on your Financial
Resources Questionnaire that you need substantially all of your
current income and liquid assets to meet ordinary and necessary
living expenses and liabilities. Note: 1) In making this decision,
we are primarily concerned with your ability to repay us now.
However, we will also consider whether your financial condition
can be expected to improve in the future. 2) If the expenses shown
on the Financial Resources Questionnaire include those of your
spouse and children, the income section must also include the
income generated by those members of your family.
b) When you received your overpayment, did it (regardless of your
current ability to repay) cause you to give up a valuable right, such
as some other benefit payment. Or, in reliance on the incorrect
payment, did you change your financial position for the worse,
such as making a commitment that you would not have made
under other circumstances.
Reverse of Part 3

c) Recovery of the overpayment would otherwise be inequitable due
to special or exceptional circumstances. Note: In the event we
determine that the overpayment exists, the amount owed is correct,
and your waiver or compromise request is denied, we may still
consider lessening the financial burden by lowering your monthly
installments. For this pupose, you should indicate on Part 2 of this
form the amount you can repay on a monthly basis to pay in full.
7. Lower Installments Or A Compromise Payment (Check the
appropriate box in item 7 on Part 2 of this form) - In the event your
reconsideration or waiver request is denied, you may also request lower
installments or offer a compromise payment. Make, on the back of Part 2,
the statements required to support your request (see the discussion of
"Lower Installments" and "Compromise" on the reverse), and complete
the Financial Resources Questionnaire.
8. VOLUNTARY REPAYMENT AGREEMENT (Check box 8 on
Part 2 of this form) - Rather than having your annuity offset, you may ask
us to let you send in regular installment payments. We have sole
discretion whether to accept such payments in place of the offset. If you
want to send your payments to us instead of having them deducted from
your annuity, you must complete Part 2 of this form. In the space titled
"Your Statement Concerning the Overpayment" show that deducting
monthly installments from your annuity would cause a financial hardship
or would be against equity and good conscience. You must also complete
the Financial Resources Questionnaire. Do not make payments until we
notify you that the voluntary repayment agreement is acceptable. If we
approve the voluntary repayment agreement and your account becomes
delinquent, we will cancel the repayment agreement and make deductions
from your annuity until the amount is paid.
D. HOW AND WHEN TO MAKE YOUR REQUEST - The
procedures for requesting copies of your records, lower installments, a
voluntary repayment agreement, reconsideration, waiver, or compromise
are as follows:
1. Complete Part 2 of this form and state your reasons for making the
request(s). If your name and address as shown are not correct, make
any necessary changes.
2. If your request is returned to us by mail, it must be postmarked within
30 calendar days after the date of this notice (see box 3) and mailed to:
Office of Personnel Management
Attn: Funds Management
P.O. Box 7125
Washington, DC 20044-7125
3. If you hand deliver your request, bring it to:
Office of Personnel Management
Retirement Information Office
1900 E Street, NW - Room 1323B
Washington, DC
4. OPM can extend the 30-day time limit only if you show that you were
not aware of the time limit or you were prevented from responding by
a cause beyond your control.
If you plan to submit additional evidence to support your request and that
information is not available, you must:
• Submit Part 2 of this form within the 30-day time limit; and
• Include in your request a statement that you will be submitting
additional evidence, a brief description of the evidence that you will
submit, your estimate of the date the evidence will be available, and a
brief explanation for the delay.
We will acknowledge receipt of your statement and consider your request
filed on time. Please send the additional evidence as soon as possible.
E. FINAL DECISION - After we consider your request, we will send
you a final decision in writing. If our decision is not in your favor, any
further rights of review available to you will be explained at that time.
Collection actions will be suspended at all levels of review if a timely
request is received, unless you become eligible for a lump sum payment
or your recurring monthly payment is scheduled to cease within one year
and (1) failure to make offset would substantially prejudice the
Government's ability to collect and (2) the time before the payment is to
be made does not permit completion of the proceedings explained above.
RI 34-3
Revised December 2012

Form Approved:
OMB No. 3206-0167

United States
Office of Personnel Management
Retirement Operations
Washington, D.C. 20415

Part 2
Request for Lower Installments, Voluntary Repayment
Agreement, Reconsideration, Waiver, And/Or Compromise
When An Overpayment Was Made From The Civil Service
Retirement and Disability Fund

1. Retirement claim number

•
2. Case name
3. This notice dated
4. To request reconsideration/waiver, reply by
5. Total to be collected

6. First installment to be collected from payment dated

Collection
Schedule

7. Number of installments

_________________ installments of $
and
a final installment of $

Period during which the overpayment accrued

8a. From

8b. To

9. Cause of overpayment:

Check the box or boxes that apply to you. You may check more than one box, unless you check boxes A.1 or A.2.

A.

B.

I accept the decision on the existence and amount of the overpayment, and I agree to make payment in full. I will not make partial payments.
I agree to make -1.

Full Payment Enclosed

My check or money order, payable to the U.S. Office of Personnel Management in the amount of
$_______________________ is enclosed.

2.

Full Payment
Within 90 Days

I will send my check or money order payable to the U.S. Office of Personnel Management in the amount of
$________________________ on or before ______________________.

I accept the decision on the existence and amount of the overpayment, but I request -3.

Lower Installments

I request lower installments. I understand that OPM generally expects to be repaid within 36 months and that
each installment be at least $50 per month. I have indicated below the amount I can pay each month.
My financial resources will allow me to have $_____________ per month deducted from my annuity. I am
submitting the Financial Resources Questionnaire and my statement on the reverse to support my request.

C.

4.

Compromise

I propose a compromise payment. I have indicated the amount and terms of my offer on the reverse. I am
submitting the Financial Resources Questionnaire and my statement on the reverse to support my request. I
understand that I must establish by substantial evidence that I am unable to repay the full amount within a
reasonable time.
I do not accept your decision to recover this overpayment from my annuity and I request -5.

Reconsideration of the
Existence or Amount of
the Overpayment

I am providing the specific reasons for my disagreement with your decision on the reverse. If the existence
and/or the amount of the overpayment is confirmed, I understand that the money will be collected as shown in
block 7 above, unless my request for waiver, lower installments, or a compromise is approved.

6.

Waiver

I am submitting the Financial Resources Questionnaire (unless my waiver request is not based on financial
hardship) and my statement on the reverse to support my request. I understand that I must establish by
substantial evidence that I am eligible for a waiver.

7.

Lower Installments or a
Compromise Payment

If the existence and/or the amount of overpayment is confirmed or my waiver request is denied, I also request
consideration for
lower installments in the amount of $__________________ per month
a compromise
payment as shown on the reverse. (Please check the applicable box.) I am submitting the Financial Resources
Questionnaire and my statement on the reverse to support my request.

8.

Voluntary Repayment
Agreement

I am submitting the Financial Resources Questionnaire and my statement on the reverse to support my request.

Remember, in the event that we determine (1) the overpayment exists and the amount owed is correct and (2) your request for a voluntary repayment agreement, waiver, or compromise is denied, we
may consider alleviating the financial burden of repayment by lowering your monthly installments. Be sure to tell us what you can repay in your response to item C.7. above.

Part 4 - File Copy
RI 34-3
Revised December 2012

Your Statement Concerning The Overpayment
(Attach additional pages if necessary)

Your signature

Telephone number (including area code) Email Address

Date

Mail to:

Office of Personnel Management
Attn: Funds Management
P.O. Box 7125
Washington, DC 20044-7125

Privacy Act Statement
OPM administers the retirement systems for Federal employees and annuitants as
authorized by chapters 83, 84, 87, and 89 of title 5, U.S. Code and Public Laws
83-589, 84-356, and 86-724. The Federal Claims Collection Act of 1966 (Public
Law 89-508) empowers the head of a Federal agency to enforce collection of claims
of the United States for money or property arising out of the activities of the agency.
Section 179.102 of title 5, Code of Federal Regulations, delegates authority to the
Associate Director for Retirement and Insurance for collection of claims arising out
of overpayments of Federal retirement benefits. The information requested on this
form is needed to determine whether you qualify for the relief you are seeking.
Intentionally false statements and/or suspected illegal activities are reportable to the
appropriate law enforcement agencies. The information you provide may be shared
with the Government Accounting Office and the United States Department of Justice
in the event litigation is required to enforce collection.

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 in order to determine benefits
under their programs, to obtain information necessary for determination or continuation
of benefits under this program, or to report income for tax purposes. 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. Provision of the
information is voluntary; however, failure to supply all the requested information or
including intentionally false statements may result in an unfavorable decision or a
financial investigation of the person who owes the United States. Pending the results of
the investigation, evidence may be turned over to the Department of Justice for
appropriate action.

Public Burden Statement
We estimate this form takes an average of 60 minutes to complete, including the time for
reviewing instuctions, 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 United States Office of Personnel Management

Reverse of Part 4

(OPM), Retirement Services Publications Team (3206-0167),Washington, D.C.
20415-3430. The OMB Number, 3206-0167, is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number
is dispalyed.

RI 34-3
Revised December 2012