Form SF 2812 SF 2812 Report of Withholdings and Contributions for Health Bene

Form Approved
OMB 3206-XXXX

Report of Withholdings and Contributions for Health Benefits
Life Insurance and Retirement
FROM: Address (including Department, Bureau, Location, and ZIP Code)

Interagency Report
No. 1064-OPM-AR

Payroll Office Number

Report Number

Month reported on Statement of Transactions

Date Payroll Paid

PAY PERIOD

From

To

Telephone number (including area code)

To: OFFICE OF PERSONNEL MANAGEMENT
ATTN: FUNDS MANAGEMENT
POST OFFICE BOX 582
WASHINGTON, DC 20044-0582
Benefit Category
Withholdings

LIFE INSURANCE

I certify that the items listed herein are correct and the amount is available to
be credited to the OPM receipt account.

Signature of authorized Administrative or Certifying Officer

Contributions

Date

Total

Basic Life
Standard - Option A
Additional - Option B
Family - Option C
Post-Retirement
Total Life Insurance
HEALTH BENEFITS
Regular
Temporary Continuation RI
Coverage (TCC) - P.L. 100-654
Total Health Benefits
RETIREMENT
CSRS
All Categories1
Salary Offset - ReemployeG
Annuitants
Military and Civilian Service Credit
FERS
Regular
Military Reserve Technicians
Special2
Salary Offset - ReemployeG
Annuitants
Military Deposit
FERS - RAE
Regular - RAE
Military Reserve Technicians - RAE
Special - RAE3
Salary Offset - ReemployeG
Annuitants - RAE
Military Deposit - RAE
Total Retirement
Grand Total
1

Employees with CPDF Retirement Codes of 1, 6, C, E, R or T.

2

Employees with CPDF Retirement Codes of L or M.

3

Employees with CPDF Retirement Codes of LR or MR.

Public Burden Statement
We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the
completed form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completing time, to the Office of
Personnel Management, Funds Management, P.O. Box 582, Washington, DC 2044. The OMB Number 3206-XXXX 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 for Personnel and Payroll
Offices

Standard Form 2812-A
This form may be locally reproduced

Revised November 2013