RI 34-017 Dec 2012 Markup

Form approved:
OMB No. 3206-0167

Financial Resources Questionnaire
Federal Employees’ Group Life Insurance Premiums Underpaid
U.S. Office of Personnel Management
Retirement Operations

General Information
The purpose of this questionnaire is to determine your eligibility for:
1.

waiver of the amount due the retirement system on the basis of
financial hardship;

2.

compromise in the amount to be paid;

3.

lower installments; and/or

4.

a voluntary payment agreement.

For more information on waiver, compromise, lower installments, or
voluntary payment, please refer to our letter or notice informing you of the
underpayment of Federal Employees’ Group Life Insurance premiums.
(Note: If you are only requesting lower installments, you do not need to
fill out this questionnaire as long as your payments will be (1) at least $50
a month and (2) sufficient to pay off the entire amount within three years.)
Failure to supply all the requested information may result in an
unfavorable decision. Please note that you may be asked to provide
verification of the information you supply in this questionnaire (e.g.,
evidence of claimed expenses).
To be considered for waiver, compromise, lower installments, or a
voluntary payment agreement, you must complete and return this
questionnaire to us within 30 days after the date shown in the notice of
underpayments.

General Instructions
1.

Please read all items carefully.

2.

Type or print in ink.

3.

Complete all items on the form. If a question does not apply, answer
“No” or “None”. Do not leave it blank. If answers require additional
space, continue them in Section X. Attach additional sheets if
necessary. Include your name and retirement claim number in the
upper right corner of each additional sheet.

4.

Sign and date this questionnaire in Section XI.

5.

Send the completed form to:
Office of Personnel Management
Attn: Funds Management
P.O. Box 7125
Washington DC 20044-7125

Detailed Instructions
Most of the questionnaire items are self-explanatory. Instructions are
provided below for those items identified with an asterisk(*), which
require further explanation.
Section I - Personal Data
Item 1 Give the name of the former Federal employee upon whose
service your entitlement to retirement system benefits was
based. (If the benefits are based upon your own service, give
your name.)
Section IV - Average Monthly Income
Item 1 Enter your current monthly gross salary - i.e., wages, fees,
commissions - for yourself and then your spouse. (Enter the
total salary paid before any payroll deductions are made; e.g.,
Federal, state, and local taxes; social security taxes; insurance,
etc.). If your salary fluctuates on a monthly basis, estimate the
monthly average.

Item 6

Enter all other current income not listed. This may include
unemployment compensation, public assistance benefits, trust
income, tax refunds, alimony, child support, royalties,
payments of debts owed to you, income provided by
dependents listed in Section I (other than spouse), etc. Estimate
the average monthly amount.

Section V - Average Monthly Expenses
Item 1 Enter the amount you currently spend on average for rent,
mortgage, homeowner/condominium fees, etc., each month. If
you include property taxes in this item, do not include them in
V.9.
Item 3 Enter the average monthly amount you spend for electricity,
telephone, gas, water, coal, oil, etc.
Item 4 Enter the average monthly amount you spend for household
maintenance (repairs, cleaning supplies, etc.) and personal
necessities.
Item 7 Enter the average monthly amount you spend for insurance
(life, health, accident, automobile, homeowners, etc.). Do not
include homeowner’s insurance if it is already included in item
V.1.
Item 8 Transportation costs include necessary automobile expenses
(gas, oil, maintenance), cab fares, and public transportation.
Item 9 Enter 1/12 of all taxes you pay in a year, including Federal,
state, and local taxes; property taxes not included in item V.1;
sales taxes not included in other items, etc.
Item 10 Enter the total amount due monthly from existing liabilities as
shown in Column E of Section VII. (This amount should not
include any expenses - such as mortgage payments - listed
under other items in Section V.)
Item 11 Other living expenses which you can prove to be ordinary and
necessary. Provide a breakdown of these expenses in Section
X.
Section VIII - Assets
Item 4 Enter the cash value of your money market accounts,
certificates of deposit, etc. Do not include Individual
Retirement Accounts (IRA’s) or other interest bearing accounts
which belong in item 6.
Item 5 The current value on any stocks or bonds you own. The current
value is the amount you would receive if you sold these
securities.
Item 6 The current value of any IRA’s, Keoughs or similar retirement
savings accounts.
Item 8 Identify any automobiles, vans, trucks, motorcycles, motor
homes (RV’s), trailers, campers, boats, etc., that you own, and
their resale value (the amount you would receive if you sold
these vehicles). Any remaining liabilities for these vehicles
should appear in Section VII.
Item 9 The resale value of your home and other real estate. (If you
own two or more properties, list separately. Also show the
unpaid amount of any real estate mortgages in Section X.)
Item 10 The current resale value of any other personal property (art
pieces, jewelry, etc.) which can be sold and which are valued in
excess of $1,000 per item. (Itemize in Section X.)

RI 34-17
Revised December 2012

Financial Resources Questionnaire
For Consideration in Connection With Collection of an Underpayment of Federal Employees' Group Life Insurance Premiums
Please read the attached instructions and Privacy Act Statement before completing this form.

Section I - Personal Data
*1. Name of former Federal employee (Last, first, middle)

2.

Claim number

3.

Former Federal employee's date of birth
(mm/dd/yyyy)

4.

5.

Your date of birth (mm/dd/yyyy)

6.

Your social security number

8.

Your telephone number (including area code)

9.

Your email address

Your name

7. Your address

10. Your dependents (list spouse first):
Relationship

Name (Last, first, middle)

Social Security Number

Date of Birth

Section II -Your Current/Most Recent Employment

Section III -Spouse's Current/Most Recent Employment

1. Current or most recent position
(e.g., Salesclerk)

1. Current or most recent position
(e.g., Salesclerk)

2. Dates of employment
From (mm/yyyy)
To (mm/yyyy)

3. Name and address of employer

3. Name and address of employer

Section IV -Average Monthly Income
Type of Income
*1. Gross salary or wages
(before payroll deductions)

2. Dates of employment
From (mm/yyyy)
To (mm/yyyy)

Section V -Average Monthly Expenses

Your Income

$

Spouse's Income

$

Type of Expense
*1. Rent/mortgage payments,
homeowner/condominium fees

Monthly Average

$

2. Food

2. Self- employment (net)

*3. Utilities
*4. Household maintenance

3. Gross retirement benefits:

5. Clothing

Military retired or retainer pay
Social Security
Payments from OPM
Other (specify)

6. Medical and dental
(non-reimbursable)
*7. Insurance premiums
*8. Transportation

4. Disability benefits
(Veterans benefits, Workers'
Compensation, etc.)

*9. Taxes (1/12 of all yearly taxes)
*10. Monthly payments on existing installment
contracts and other debts
(Total from Section VII)

5. Investments
(interest, dividends, rental income,
etc.)
*6. Other (itemize in Section X)

7. Total average monthly income
(add items 1 thru 6)

*11. Other ordinary and necessary living expenses

$

$

12. Total average monthly expenses
(add items 1 thru 11)

$

*See "Detailed Instructions" for an explanation of this item.
RI 34-17
Revised December 2012

Section VI - Summary
1. Total Monthly Income
(Section IV, line 7, combined)

$

2. Total Monthly Expenses
(Section V, line 12)

-

3. Balance
(Subtract line 2 from line 1 above)

$

4. How much of the balance in item 3 can you apply toward
repayment on a monthly basis?

$

5. If your monthly expenses exceed your monthly income, how do you pay the difference?

Section VII - Installment Contracts and Other Debts
Show here all debts which you are required to pay in regular monthly installments, such as car, television or appliance payments to dealers, banks, or financial companies;
repayment of money borrowed for any purpose; charge accounts and credit card payments; doctor or hospital bills; taxes owed; etc. Do not include expenses (such as mortgage
payments) already listed in Section V, exclusive of item 10. Note: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay
in Section X.
(A) Name and Address of Creditor

(C) Original
Amount of Debt

(B) Purpose of Debt

Total

(D) Unpaid
Balance

(E) Amount
Due Monthly

$

$

$

$

$

$

(F) Scheduled Date
of Full Repayment

Section VIII - Assets
Type of Asset

Value

$

1. Cash on hand

Type of Asset

Value

$

*6. Individual Retirement Accounts

2. Checking account(s). Give name and address of
financial institution(s) below

$
$

7. Debts owed to you (give name of debtor)

$

$
3. Savings account(s). Give name and address of financial
institution(s) below

*8. Vehicles
Type of Vehicle

Make

Model

Year

$

$

$

$
*4. Other interest-bearing account(s)

Resale Value

$
*9. Resident real property & other real property owned
(itemize below or in Section X)

$
$

$
*5. Stocks, bonds, and other securities
(itemize below or in Section X)

$
$

$
$
$

*10. Other assets (itemize in Section X)
11. Total assets (total of lines 1 thru 10)

*See "Detailed Instructions" for an explanation of this item.

$
$

Section IX - Additional Data
If "Yes", give details in Section X.

Yes

No

1. Is anyone holding money or assets on your behalf?
2. Is there any likelihood that you will receive an inheritance or benefits from a trust?
3. Do you have any of the incorrectly paid checks in your possesion?
(If "Yes", show the total amount and return the checks immediately.)

$

Section X - Remarks
Use this space and additional sheets if necessary to supply any other pertinent information and to continue your answers to previous items. Indicate section and item number to
which your comments apply.

Section XI - Certification
I affirm that the information provided herein is true, correct, and complete to the best of
my knowledge and belief.
1. Your signature

2. Date (mm/dd/yyyy)

Warning
Any intentionally false statement, concealment of material fact or
willful misrepresentation relative to this questionnaire is
punishable by a fine of not more than $10,000 or imprisonment
for not more than 5 years, or both (18 U.S.C. 1001). You may be
asked to furnish verification of any statement you make.

Privacy Act Statement
The Office of Personnel Management (OPM) administers the Civil Service Retirement System and the Federal Employees Retirement System for Federal employees 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 as amended (Public
Law 89-508) empowers the head of a Federal agency to enforce collection of claims for the United States of money or property arising out of the activities of the agency. Public
Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a social security number or tax identification number. This is an
amendment to title 31, Section 7701. The information requested on this form is needed to evaluate your financial ability to repay OPM. The information may be shared with the
General 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 requested information may result in a thorough financial investigation or a decision
adverse to you. Pending the results of the investigation, evidence may be turned over to the Department of Justice for appropriate action. Intentionally false statements and/or
suspected illegal activities are reportable to the appropriate law enforcement agencies.

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
(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 displayed.