RI30-003_2013_06_MarkUp

United States
Office of Personnel Management
Retirement Operations

Boyers, PA 16017

Form Approved
OMB No. 3206-0140

Information Necessary for a Competency Determination
An original or a certified copy of a court order appointing a guardian or fiduciary to handle the affairs of the individual
should be submitted so that the Office of Personnel Management can determine whether the applicant is or was
mentally incompetent or otherwise unable to handle his or her financial or other affairs. Uncertified photocopies are not
acceptable. The court order should cover the entire period of time which is in question for this determination and
should address whether the alleged incompetency occurred in the past or is currently present.
If no guardian or fiduciary is appointed by a court, please provide the information described in both A and B below.
A.

B.

A statement from the physician who has been treating the individual. (The individual or his representative is
responsible for any cost incurred in obtaining this documentation.) The physician's statement should cover, but
not be limited to, the time period in question for this competency determination and should address whether the
alleged incompetency occurred in the past or is currently present. The physician should provide, on his or her
letterhead stationery, the information listed below. Please provide a copy of this form to the physician.
•

History of the specific medical condition(s) which caused the individual to be incompetent, including
symptoms, physical findings, results of laboratory studies, and therapy (together with the response to
therapy). Please provide copies of all reports of laboratory studies, in the case of psychiatric disorders, the
findings of mental status examinations and copies of all psychological test reports, and copies of all
discharge summaries of hospitalizations and operative reports.

•

The diagnosis should be in accordance with ICD terminology or, in the case of psychiatric disorders, with
DSM IV criteria.

•

The duration of the medical condition(s), including the date the condition caused incompetency and the date
or expected date of full or partial recovery.

Affidavits from at least two persons who know the facts concerning the individual's competency, preferably one
from a member of the individual's immediate family and one from a non-family member. The persons making the
affidavits should state:
•

The relationship to, and amount of contact with, the individual during the relevant time period.

•

What actions or incidents were personally observed which would show whether the individual's condition
interfered with the ability to handle personal affairs, and how often these were observed.

•

The reason why a guardian or fiduciary was not appointed by the court to handle the affairs of the individual.

•

Who has been handling the individual's affairs.

(Affidavits must be sworn to or affirmed before a notary public or other officer who is authorized by law to
administer oaths.)
Send the documents to the above address. Be sure to include the claim number shown at the top of form RI 20-7,
Representative Payee Application, with this correspondence.
Warning
Affidavits and other evidence are subject to verification by personal investigation. Any intentionally false statement, willful concealment of a 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)
Public Burden Statement
We estimate providing this information takes an average 60 minutes per response, including the time for reviewing instructions, getting the needed
data, and reviewing the requested information. Send comments regarding our estimate or any other aspect of this form, including suggestions for
reducing time needed, to the Office of Personnel Management (OPM) Retirement Services Publications Team (3206-0140), Washington, D.C.
20415-3430. The OMB Number 3206-0140 is currently valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.
Previous edition is usable

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RI 30-3
Revised June 2013