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

Form Approved
OMB 3206‐XXXX

Report of Withholdings and Contributions for Health Benefits By Enrollment Code
Department or establishment

Payroll Office number

Report number

Bureau, division or office

Pay period from

Pay period to

Address (including ZIP Code )

Date payroll paid
Agency telephone number                                                

Enrollment

Total Withholdings Number

Enrollment

Total Withholdings Number

Enrollment

Total Withholdings

Number

Code No.

& Contributions

Code No.

& Contributions

Code No.

& Contributions

enrolled*

enrolled*

enrolled*

*Number of enrollees is required on report, for 
the last payroll periods paid during the 1st through the 15th of March and September.
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