Form RI 25-41 RI 25-41 Initial Certification of Full-Time School Attendance

Form Approved
OMB No. 3206-0099

United States
Office of Personnel Management
Retirement Operations
Washington, DC 20415

Initial Certification of
Full-Time School Attendance
Reference
Date (mm/dd/yyyy)
Claim number

•

(suffix)

CSF

Name of deceased employee
Name of child
Date of death (mm/dd/yyyy) On roll?

The Application for Death Benefits shows that the child named
above, a survivor of a Federal employee or annuitant, is (or soon
will be) age 18. After reaching age 18, a child is eligible for a
survivor annuity only if unmarried and (1) a full-time student in an
accredited school or (2) incapacitated for self-support because
of a physical or mental disability that began before age 18.
If a child is unmarried and incapacitated for self-support because
of a mental or physical disability, do not fill in the other side of
this form. Instead, return the form to us with a doctor's certificate
describing the nature and extent of the child's disability. After we
review the documentation of the disability, we will write to you
about the child's eligibility for benefits.

Yes

No

If the child is unmarried and a full-time student, you should
complete Part A on the other side of this form; a school official
(the principal, administrator, registrar, etc.) should complete Part
B, and you should return the completed form to us promptly. If
the child's school year was not in session on the date of death
(shown above), have the school official complete Part B for the
last school year attended.
Send the completed form to:
U.S. Office of Personnel Management
Retirement Operations
1900 E Street, NW
Washington, DC 20415-3563

Privacy Act Statement
The Office of Personnel Management (OPM) administers the Civil Service Retirement System (Chapter 83, title 5, U.S. Code) and the Federal Employees
Retirement System (Chapter 84, title 5, U.S. Code). The information requested on the enclosed form is needed to document a retirement benefit or claim.
The 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 from OPM, 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. Executive Order 9397 (November 22, 1943)
authorizes the use of the Social Security Number. Providing the information is voluntary; however, failure to supply all the requested information may delay
or prevent action on the benefit or claim. Intentionally false statements and/or suspected illegal activities are reportable by us to the appropriate law
enforcement agencies.

Public Burden Statement
We estimate this form takes an average 90 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, Retirement Services Publications Team (3206-0099), Washington, DC 20415-3430. The OMB Number 3206-0099 is
currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

(THIS SPACE IS FOR THE USE OF THE OFFICE OF PERSONNEL MANAGEMENT ONLY.)
Remarks:

Approved

Inspector

Previous editions are usable.

Not Approved Because
Less than full-time school attendance
Not in school
Over 5-month break in attendance
Married
Non-recognized school
Other (specify)
Date (mm/dd/yyyy)

Call up (M-Card) processed

Benefits specialist
Date (mm/dd/yyyy)
RI 25-41
Revised February 2013

Part A - To be completed by the payee (the person who expects to receive benefits for the student).
Read the reverse side of this form before answering the questions below; give full information; typewrite or print in ink.
1. Student's name (first, middle, last)
4. Is the student married?

Current
Status

Future
Plans

Payee
Signs
Here

2. Student's date of birth (mm/dd/yyyy) 3. Student's Social Security Number

Date of marriage (mm/dd/yyyy)
If "Yes," show the date at right, sign item 7 of this part, and
return this form. (It is not necessary to complete the rest of the
No
form.)
Last attended school (mm/dd/yyyy)
5. Is the student enrolled in
Yes
school on a full-time basis
If "No," show the date the student last attended
No
at the present time?
school on a full-time basis.
6. After the end of the school
Yes
If "Yes," give the details in items 6a and 6b.
year, does the student
intend to continue as a
No
full-time student with less
If "No" or "Undecided," go to item 7.
than a 5-month break
Undecided
between school years?
Yes

}

6a. Enter the date (or approximate
date) the next school year or
term begins after current
enrollment (month, day, year).

6b. Complete name and mailing address (including ZIP code) of the educational institution the
student will attend next year.

7. I certify that all information given in this certification is true and correct to the best of my knowledge and belief. I understand that
I must immediately notify the Office of Personnel Management (OPM) if the student transfers to another school, discontinues
school attendance, reduces attendance to less than full-time, marries, or dies. I further agree to return all overpayments of
student benefits, including overpayments that may be erroneously made after I notify OPM of any terminating event. I authorize the
appropriate school official to verify the student's school attendance status to OPM in the manner requested by that agency.
Signature of payee

Email address

Daytime telephone number Date (mm/dd/yyyy)
(

)

Part B - To be completed by an official of the educational institution for the school year

to
(month, year)

1. Is/was the student enrolled in and attending a
full-time course of resident study or training
(not correspondence) for the period requested?
Yes

2. Actual date the student started school for the
school year indicated above (mm/dd/yyyy)

3. Official ending date of the
school year (mm/dd/yyyy)

No

4. Check the type of educational institution:
High school

Vocational institute

Trade school

Junior college/
community college
College or
university

Technical institute

.
(month, year)

5. Show the complete name and mailing address
(including ZIP code) of the educational institution.
Other (specify)

6. Show the total school hours per week:
a. If college or equivalent, show credit hours
b. If high school or equivalent, show actual clock hours
c. If in a work-study program sponsored by the school,
show hours at work
hours at school

Complete items 7 and 8 below if your institution is not a state college, state university, or public high school.
7. Show the complete name and address (including ZIP code) of the
8. If the educational institution is licensed, show:
organization which accredits, licenses, or otherwise recognizes the school.
a. Current license number:

I certify that the information given in regard to requested school enrollment of the
above-named student is true and correct to the best of my knowledge and belief.

School
Official Signature of principal, administrator, registrar, etc.
Signs
Here Title

Telephone number
(
)
Date (mm/dd/yyyy)

b. Expiration date of current license
(mm/dd/yyyy)

Warning: Any intentionally false statement, willful
concealment of material fact, or use of a writing or
document knowing the same to contain a false,
fictitious, or fraudulent statement or entry, is a violation
of the law punishable by a fine of not more than $10,000
or imprisonment of not more than 5 years, or both. (18
U.S.C. 1001)
Reverse of RI 25-41
Revised February 2013