Form SF 3106/SF 3106A SF 3106/SF 3106A Application for Refund of Retirement Deductions/Current/

Form Approved:
OMB Number 3206-0170

Application For Refund of Retirement Deductions
Federal Employees Retirement System

See the attached sheets for instructions and information
concerning your application for refund of retirement
deductions and a Privacy Act Statement.

To avoid delay in payment:
(1) Complete both sides of application in full; (2) Type or print in ink.

Federal Employees
Retirement System

1. Name (last, first, middle)

2. Date of birth (mm/dd/yyyy)

3. Social Security Number

4. List all other names you have used (including maiden name, if applicable.)
5. Your address (number and street, city, state and ZIP Code) - We cannot authorize payment if this address is erased or otherwise changed.

Telephone no. (including area code)

(

Email Address

)

6. List below all of your civilian and military service for the United States Government. Attach a continuation sheet with your name and Social Security Number if necessary.

Department or Agency
(Including bureau, branch, or division
where employed)

Location of Employment
(City, State and ZIP Code)
and Payroll Office Number
(if known)

Title of Position
(Indicate if the
position was civilian [c]
or military [m])

Periods of Service
Beginning Date
(mm/dd/yyyy)

Have you paid
deposit or redeposit
for any period
including
military service?
(Check one)
Not
Fully or
Not
Paid
Withheld Withheld Partially
Indicate whether
retirement
deductions were
withheld from your
salary. (Check one)

Ending Date
(mm/dd/yyyy)

7. Have you accepted any further employment with the Federal government or the Government of the District of Columbia (or arranged for such employment) to become effective within 31 days from the ending date of your last
period of service?
No, skip items 8, 9, and 10. Continue with item 11.
Yes, continue with item 8.
8. If you answered "Yes" to Item 7, are Federal Employees Retirement System or Civil Service Retirement System deductions being withheld from your salary during
9. Date of new appointment (mm/dd/yyyy)
(Expected date if not yet reemployed.)
such employment?
Yes
No
10. Department or agency, including bureau, or division, and location (City, State, ZIP Code) where you are (or will be) employed.

11. Are you now married? If "Yes," complete SF 3106A, Current/Former Spouse's Notification of Application for Refund of Retirement Deductions, or other required information described in this package.
No

Yes, list the name of your current spouse:

12. Have you been divorced?
No

Yes

If your answer is "yes" and you have at least 18 months of creditable civilian service, complete an SF 3106A (attached) for each living former spouse to whom you were married for at least 9 months. List
the former spouses in the space given below.
Name of former spouse(s)

U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

Continue on Reverse
(You MUST complete both sides of this application.)

Date of marriage
(mm/dd/yyyy)

Date of divorce
(mm/dd/yyyy)

SF 3106 (page 1)
Revised September 2013
Previous editions are not usable

13. Indicate how you wish to have your refund paid to you if it is $200 or more. If your refund is less than $200, the Office of Personnel Management (OPM) cannot roll it over. It will be paid directly to you via Direct Deposit. Please
carefully read all of the information provided with this form, including the Special Tax Notice Regarding Rollovers, before you make your decision. An error in completing this form could delay your payment or cause payment in a
manner you did not intend. If you elect to roll over less than 100% of your refund, the total amount you roll over to any one organization must be at least $500. Make one choice in each section below, unless you need additional
information. If you need additional information before making this election, check the box in the last section.
Pay the INTEREST PORTION (Taxable Portion) of my Refund
Pay ALL by check made payable to me, with 20% Federal Income Tax Withholding.
Pay ALL by check made payable to my Individual Retirement Arrangement (IRA) or Eligible Employer Plan. (Your financial institution or employer plan must complete the financial institution certification form in this package.)
Name of Financial Institution or Employer Plan ________________________________________________________________________________________________________________________________
This rollover is to a Roth IRA
Mail the check

Withhold 20% Federal income tax from amount rolled over to Roth IRA

to the above institution or plan.
to me. I will deliver the check to the above institution or plan.

Pay ALL to my Thrift Savings Plan Account. (You must sign and submit form TSP-60, Request for a Transfer Into the TSP, to OPM. Form TSP-60 is available on the internet at www.tsp.gov.)
Pay the CONTRIBUTION PORTION (After-Tax Portion) of my Refund – (The Thrift Savings Plan will not accept this portion of your refund.)
Pay ALL by check made payable to me.
Pay ALL by check made payable to my IRA or Eligible Employer Plan. (Your financial institution or employer plan must complete the financial institution certification form in this package.)
Name of Financial Institution or Employer Plan________________________________________________________________________________________________________________________________
This rollover is to a Roth IRA
Mail the check

Withhold 20% Federal income tax from amount rolled over to Roth IRA

to the above institution or plan.
to me. I will deliver the check to the above institution or plan.

I Need Additional Information Before I Decide
I elect to have my refund computed and a rollover package with all my options sent to me before I decide how it should be paid. (Electing this option delays payment of your refund at least an additional 30 days.)
Payment Instructions
Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department of the Treasury. This does not apply to you if your permanent
payment address is outside the United States in a country not accessible via direct deposit.
Please select one of the following:
Please send my survivor annuity payments directly to my checking or savings account. (Go to item X.)
Please send my survivor annuity payments to my Direct Express debit card. (Go to Item 14 [Applicant Certification].)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to Item 14 [Applicant Certification].)
Direct Deposit
Public Law 104-134 requires that most Federal payments be paid by Direct Deposit through Electronic Funds Transfer (EFT) into a savings or checking account at a financial institution. However, if receiving your payment
electronically would cause you a financial hardship, or a hardship because you have a disability, or because of a geographic, language or literacy barrier, you may invoke your legal right to a waiver of the Direct Deposit requirement,
and continue to receive your payment by check. Therefore, you must select one of the following:
Please send my annuity payments directly to my checking or savings account.
Receiving my annuity payment(s) electronically would cause me a financial hordship, or a hardship because of a disability, or because of a geographic, language or literacy barrier. I hereby invoke my legal right to a waiver of the
Direct Deposit requirements of Public Law 104-134. Please send me my payments by check.
My permanent payment address is outside the United States in a country not accessible via direct deposit.

Continue to the next page of this form
(You MUST complete all sides for both pages of this application.)

SF 3106 (reverse of page 1)
Revised September 2013

Direct Deposit (continued)
Financial institution routing number (You may obtain this number by calling your bank, credit union, or
savings institution. This number is very important. We cannot pay by direct deposit without it. We suggest
you call your financial institution to verify this number.)

Checking or savings account number

What kind of account is this?

Checking
Savings
Telephone number of your financial institution
(including area code)

Name and address of your financial institution

(

)

Special Note: If you prefer, you may attach a cancelled personal check that shows the information requested above, instead of filling in the requested financial instituion information. If you attach your
personal check, it is especially important that you contact your bank, credit union, or savings institution to confirm that the information on the check is the correct information for direct deposit. (Some
institutions, especially credit unions, use different routing numbers on checks.) OPM can use this information to start paying you by direct deposit.
14.

Applicant Certification: I understand that I am not legally entitled to receive a refund if I am reemployed or otherwise assigned to a position under the Federal Employees Retirement System or Civil Service Retirement System
within 31 days of separating from my most recent position. I agree to notify OPM if I am employed again within this time period and to return or repay any refund paid to me if it is determined that I was not legally entitled to that
refund.
I understand that if I was not employed under the Federal Employees Retirement System on/after October 28, 2009, payment of a refund will result in permanent forfeiture of any retirement rights that are based on the
period(s) of Federal Employees Retirement System service which the refund covers, as explained in this package.
I understand that if I was employed under the Federal Employees Retirement System on/after October 28, 2009, the service covered by the refund cannot be used in the computation of my FERS annuity unless I redeposit the
refund with interest. If I do not redeposit the refund, the service can still be used toward eligibility for a FERS annuity benefit, but not in the computation of the benefit. I understand that I must be reemployed under FERS
to pay the redeposit.

I hereby certify that all statements in this application, including any information I have given elsewhere in this form, are true to the best of my belief and knowledge and that the tax withholding election made here reflects my
wishes.
Signature

Date (mm/dd/yyyy)

Warning: Any intentional false statement in this application or willful misrepresentation relative thereto 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)
For agency use only: I certify that this agency received this Standard Form 3106 on the date shown.
Signature of agency official

Date received (mm/dd/yyyy)

Title

Agency Payroll Office number

Continue on Reverse
(You MUST complete all sides of this application.)

SF 3106 (page 2)
Revised September 2013

Certification by Financial Institution or Eligible Employer Plan
If Applicant Elects to Roll Over a Refund of Retirement Deductions
This must be completed by your financial institution or eligible employer plan.
Name of applicant (last, first, middle)

Social Security Number

Name of institution or employer plan

Account number

Certification: My signature below confirms the account number for the individual named in item 1 on the first
page of this form. As a representative of the financial institution or plan named above, I certify that this
institution or plan agrees to accept the funds described above as a direct trustee-to-trustee transfer from the Office
of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as defined in the Internal
Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand that
my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated above.
Typed or printed name of certifying representative

Address of institution or employer plan

Phone number (including area code)

(

)

Signature of certifying representative

Date of certification (mm/dd/yyyy)

Certification by Financial Institution or Eligible Employer Plan
If Applicant Elects to Roll Over a Refund of Retirement Deductions
This must be completed by your financial institution or eligible employer plan.
Name of applicant (last, first, middle)

Social Security Number

Name of institution or employer plan

Account number

Certification: My signature below confirms the account number for the individual named in item 1 on the first
page of this form. As a representative of the financial institution or plan named above, I certify that this
institution or plan agrees to accept the funds described above as a direct trustee-to-trustee transfer from the Office
of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as defined in the Internal
Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand that
my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated above.
Typed or printed name of certifying representative

Phone number (including area code)

(
Signature of certifying representative

Address of institution or employer plan

)
Date of certification (mm/dd/yyyy)

Instructions for Rollover to the Federal Retirement Thrift Savings Plan
The Thrift Savings Plan (TSP) will not accept non-taxable (post-tax) monies. You must have an open TSP account. Before the Office of Personnel
Management (OPM) can complete a rollover to your Thrift Savings account, you must sign and submit Form TSP-60, Request for a Transfer Into the
TSP, to OPM. Submit both the TSP-60 and this form, SF 3106, at the same time. OPM will complete its portion of the form and fax it to the Thrift
Savings office for processing. The form must be approved by the Thrift Savings Board and the Board must notify OPM to transfer the funds.
Form TSP-60 is available on the internet at www.tsp.gov.

SF 3106 (reverse of page 2)
Revised September 2013

Current/Former Spouse's Notification of Application for Refund of Retirement Deductions
Under the Federal Employees Retirement System
If you apply for a refund of retirement deductions, you must notify your current spouse. Also, you must notify any former spouse if the following
conditions apply: (1) You have 18 months of creditable civilian service; and (2) You were married to the former spouse for at least 9 months. Refer to
the information and instructions given on this form.
Part 1 - To Be Completed By Applicant
Instructions: To notify each current or former spouse of your application for a refund of your retirement deductions, complete Part 1 with your name,
date of birth and Social Security Number and have the current or former spouse complete Part 2. The current or former spouse's signature must be
witnessed in Part 3. You may not be a witness. After Parts 2 and 3 have been completed, the form must be returned to you for attachment to your
refund application. (Use a separate form for current spouse and each former spouse.)
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

Part 2 - To Be Completed by Current or Former Spouse
Instructions: Complete Part 2 and have two witnesses complete Part 3 and then return the form to the applicant. Payment of the refund of
retirement deductions will end any entitlement you may have to a survivor annuity or portion of any annuity to which the applicant would otherwise
have been entitled. If a court order expressly relates to the applicant's retirement deductions and you believe that payment of the refund would end a
court-ordered entitlement you have to a survivor annuity or to a portion of an annuity to which the above-named person is entitled, see the
information provided below regarding such court orders. (Complete Part 2 and have the witnesses complete Part 3 even if you are submitting a court
order.)
I have read the paragraph above
and I understand that the
above-named individual is applying
for a refund of retirement
deductions under the Federal
Employees Retirement System.

Signature (do not print)

Date signed (mm/dd/yyyy)

Name (type or print legibly)

Part 3 - To Be Completed by Witnesses
We, the undersigned, certify that Part 2 of this form was signed by the current or former spouse of the person named in Part 1 in our presence.
Signature

Date signed (mm/dd/yyyy) Signature

Date signed (mm/dd/yyyy)

Name of witness (type or print legibly)

Name of witness (type or print legibly)

Address (number and street)

Address (number and street)

City, state and ZIP code

City, state and ZIP code

Information About Sending Court Orders to the Office of Personnel Management (OPM)
If you are legally separated or divorced from the applicant, you should know that a
refund would end your potential entitlement to a survivor annuity and to any portion
of any annuity to which the applicant would be entitled. If you have a court order
that expressly relates to any portion of the applicant’s retirement deductions, you
should send a copy of the court order to OPM with a cover letter giving:
1.

The name, date of birth, and Social Security Number of the person applying for
the refund;

2.

Your statement that the court order has not been amended, superseded, or set
aside.

3.

Your name, date of birth, and mailing address; and

4.

If the court order states that any payments to you are subject to termination
upon your remarriage, a statement that either (1) you have remarried and the
date of the remarriage, or (2) that you have not remarried and that you will
notify OPM within 15 days of a remarriage should you remarry in the future.

If the court order gives you a survivor annuity after the death of the applicant, also
attach a copy of your birth certificate, if available.

The court order can be honored only if it is received before the refund is paid to
the applicant. Payment of the refund will end any entitlement you may have to a
survivor annuity or a portion of any annuity to which the applicant would otherwise
have been entitled. Payment of the refund will also end any eligibility you have to
coverage under the Federal Employees Health Benefits Program. Send a copy of the
court order and your cover letter to the following address and complete the blocks
below:
Office of Personnel Management
Federal Employees Retirement System
Attn: Refund
P.O. Box 45
Boyers, PA 16017-0045
NOTE: A former spouse who remarries before reaching age 55 is not entitled to a
survivor annuity. (Termination of the remarriage does not restore a former spouse’s
entitlement to a survivor annuity.) Remarriage does not affect a former spouse’s
court-ordered right to receive a portion of any annuity during the annuitant’s
lifetime, unless the court order provides otherwise. A former spouse may also lose
entitlement according to the court order.

I believe I have a court order that meets the criteria described above. I am immediately submitting a copy of the court order and the required cover
letter to the address provided above.
Signature (do not print)

U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

Date of court order (mm/dd/yyyy)

Today's Date (mm/dd/yyyy)

SF 3106A
Revised September 2013
Previous editions are not usable.

Notification To Current and Former Spouses of Your Refund Application
The Federal Employees Retirement law provides that your retirement
contributions may be refunded to you only if you notify the following
persons that you are applying for a refund:
•

any current spouse (including any person from whom you are
legally separated) and

•

any former spouse who is still living.

You are not required to notify a former spouse if you were not married
to that person for a total of at least 9 months or you do not have a total
of at least 18 months of creditable civilian service.
You should provide a copy of Standard Form 3106A, Current/Former
Spouse’s Notification of Application for Refund of Retirement
Deductions (this form, front and back), to (1) your current spouse,
if any, and (2) if you have at least 18 months of creditable civilian
service, each former spouse that meets the above criteria. The current
and/or former spouse(s) must sign the form and have the signature
witnessed by two persons. You cannot be one of the witnesses.
Additional copies of the SF 3106A should be available from your
employing office or you can photocopy both sides of the form
for each spouse/former spouse. SF 3106A is also a part of the
SF 3106 forms package which is found on our website at
www.opm.gov/forms.
In addition, the law provides that payment of your refund is subject to
the terms of any court order (related to a divorce or legal separation)
that expressly relates to any portion of your refund, if the payment of
the refund would end the entitlement of a spouse or former spouse to a
survivor annuity or a portion of your annuity. A court order cannot bar
payment of a refund if you do not have a future annuity entitlement
under the Federal Employees Retirement System.

or 2. The current mailing address of the current or former spouse.
(You may use the box at the end of this column to give the
address.) The Office of Personnel Management (OPM) will
attempt to notify (by certified mail return receipt requested) the
current or former spouse at the address you give. OPM will not
pay you the refund until we receive the signed return receipt.
If the notice is undeliverable at the address you give, your refund
may not be paid unless you subsequently show that the
notification requirement should be waived as described below.
If you decide you want OPM to make notification, it will cause
a 6- to 8-week delay in the payment of your refund.
If you do not know the current whereabouts of a spouse or former
spouse, OPM may waive the requirement to notify that person. A
waiver may be granted if you submit with your refund application:
1.

A determination by a court or administrative agency empowered
to make such determinations that the person is missing; or

2.

Notarized statements from yourself and two other persons (one of
whom is unrelated to you) stating that the person’s whereabouts
are unknown and detailing efforts to locate the person.

I have been unable to notify the following current or former
spouse. (Enter name and current mailing address, including
ZIP Code, of the current or former spouse.)

Attach all signed and witnessed notification forms to your refund
application.
If your current or former spouse refuses to acknowledge the
notification or you are otherwise unable to obtain the acknowledgment,
you must submit one of the following:
1.

Affidavits signed by two individuals who witnessed your attempt
to personally notify the current or former spouse. The witnesses
must attest that they saw you give or try to give (personally) the
notification form to your current or former spouse to whom your
purpose should have been clear.

Privacy Act Statement
5 U.S.C. 8424 authorizes solicitation of this information. The information you furnish will be used to identify records properly associated with your application for
Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a uniquely identifiable claim file. 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 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.
Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number to distinguish between the applicant and people with similar names. Failure
to furnish the requested data may result in our inability to refund the retirement deductions.

Public Burden Statement
We estimate that this form takes an average of 5 minutes 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 (3206-0170), Washington, D.C. 20415-3430. The OMB Number 3206-0170 is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is displayed.

Reverse of SF 3106A
Revised September 2013

Instructions For Completion of Your Application For Refund of Retirement Deductions
Special Information for Applicant
1. You must complete questions 1 through 14 on the refund application.
Additionally, your financial institution(s) must complete the Certification
by Financial Institution or Eligible Employer Plan found in this package,
if you elect to roll over the refund into an individual retirement arrangement (IRA) or eligible employer plan. Your current and/or living former
spouse(s) must each complete a separate SF 3106A to document notification of your application if you are or have been married.
2. If you were employed under the Federal Employees Retirement System
(FERS) on or after October 28, 2009, you must repay any refund you
receive of your FERS deductions in order to receive credit for the service
in the computation of your annuity. If you do not repay the refund, the
service will be excluded from your annuity computation, but it will still
be used to determine your length of service for annuity eligibility
purposes.
If you were not employed under FERS on or after October 28, 2009,
payment of a refund of your FERS deductions will permanently eliminate
your retirement rights for the period(s) of FERS service which the
refund covers. This includes a refund of any deposit you have paid for
military service performed after 1956. You will not be permitted to pay
the money back, even if you are later reemployed in the government.
The service involved cannot be used in computing annuity benefits that
you may later become entitled to receive under FERS nor can it be used
in determining length of service for annuity eligibility purposes.
Payment of the refund will end eligibility any former spouse(s) may
have to coverage under the Federal Employees Health Benefits Program.
Payment of the refund does not, however, affect credit for leave or other
non-retirement purposes.
3. A refund of retirement deductions cannot be paid prior to 31 days after
the date of separation from a position subject to FERS or the Civil
Service Retirement System (CSRS) or within 31 days before the earliest
commencing date of any annuity for which you are eligible, including an
annuity which must be reduced for age.
Payment of a refund is prohibited if you are currently employed in a
position subject to FERS or CSRS deductions or will be eligible to retire
within 31 days from the date of OPM’s receipt of the refund application.
4. Interest will be paid on your FERS refund at the same rate earned by
government securities if the period(s) of service which the refund covers
totals more than one year.
5. For additional information about your benefits if you decide not to apply
for this refund, see the booklet FERS (RI 90-1), which is available from
your agency.
6. Do not offer this application to a person or a financial institution as
collateral or security for a loan. A former employee must apply for a
refund personally and payment must be made directly to him or her
(except direct rollovers, as described in the Federal Tax Information
section). However, outstanding debts to the U.S. Government can, at the
Government’s request, be withheld from a refund, provided all legal
requirements are met.
Transfers to FERS
Completion of this application will authorize OPM to refund all retirement
deductions to your credit under both FERS and CSRS. Any interest payable
is computed using the rules for the retirement system under which the
deductions are credited.
If you have deductions creditable under CSRS and receive a refund, you can
pay back the amount of the CSRS deductions plus interest if you are later
reemployed in the Federal government. The CSRS service can be used in
determining length of service for annuity eligibility even if you do not repay
the money. If you want only a refund of your CSRS deductions and not
your FERS deductions, attach a signed statement to your completed
application.
For additional information, see the FERS Transfer Handbook (RI 90-3)
which is available from your agency and on our website at
www.opm.gov/retirement-services/.
Federal Tax Information
Applicants are permitted to roll over their refund of retirement contributions
to an IRA or an eligible employer plan. The actual retirement contributions
are not taxable. However, any interest paid on the contributions is taxable.
If OPM pays the interest to you, 20% Federal income tax must be withheld.
If the taxable portion is rolled over, we will not withhold any Federal income
tax, unless it is rolled over to a Roth IRA and you elect to have 20% tax
withheld on this form. If you roll your whole refund into an IRA, you are
responsible for accounting separately for the taxable and non-taxable portions.

If you want to roll your whole refund into an eligible employer plan, you are
responsible for selecting a plan that accounts separately for the taxable and
non-taxable portions. Please note that the Federal Retirement Thrift Savings
Plan will accept the taxable portion of your refund (interest portion), but
will not accept the non-taxable portion (actual retirement contributions).
If your refund is less than $200, we are not required to withhold 20% of the
interest for Federal income tax and we cannot roll over any of the amount.
You can still roll over an amount equal to the refund personally after we
send the payment to you.
You must complete Question 13 on the refund application, instructing us
how to pay any refund you may be due to receive. Since we cannot tell you
how much your refund will be until we receive your application and
complete the calculation, you can instruct us to prepare an election form
telling you the amount you can roll over (if it is over $200) after we
compute the benefit. If you ask for this detailed information, your case will
be held until we send and receive your written election, usually a delay of
payment of at least 30 days.
If you elect to roll over any portion of the refund into an IRA or eligible
employer plan, your financial institution or employer plan must complete
the certification found in this package, before we can process your election.
Two certification forms are provided, since you can roll your refund over to
two different institutions. If you elect to roll over less than 100% of your
retirement deductions, the total amount you roll over to any one
organization must be at least $500.
More information is given in the Special Tax Notice Regarding Rollovers,
found in this package. Consult a qualified tax advisor or the Internal
Revenue Service if you need more information on tax matters. OPM
cannot provide you with tax publications or tax advice. You should be
aware that distributions made from the plan to which the rollover is made
may be subject to different restrictions and tax consequences than those that
apply to distributions from OPM.
If you do not complete an election, and your refund is $200 or more, we
will pay your refund directly to you and will withhold 20% of any interest
payable for Federal income tax. You have the option to roll over part or all
of the refund yourself within 60 days after you receive the payment. If
your refund is less than $200, we will pay your refund directly to you and
no tax will be withheld.
Where to File Your Application
1. If you have been separated 30 days or less, this application should be
forwarded to the office in which you were last employed. If you need to
check on the status of your application, first verify that your former
agency has sent it, along with your records, to OPM.
2. If you have been separated more than 30 days, forward this application
to the Office of Personnel Management, Federal Employees Retirement
System, P.O. Box 45, Boyers, PA 16017-0045.
3. If you want to withdraw your Thrift Savings Plan account balance, ask
your agency for information. This is not the form you would use.
Privacy Act Statement
Solicitation of this information is authorized by the Civil Service Retirement law
(Chapter 83, title 5, U.S. Code) and the Federal Employees Retirement law (Chapter
84, title 5, U.S. Code). The information you furnish will be used to identify records
properly associated with your application for Federal benefits, to obtain additional
information if necessary, to determine and allow present or future benefits, and to
maintain a uniquely identifiable claim file. 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 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.
Executive Order 9397 (November 22, 1943) authorizes use of the Social Security
Number to distinguish between you and people with similar names. Failure to furnish
the requested data may result in our inability to determine your eligibility to receive a
refund of retirement deductions.
Public Burden Statement
We estimate that 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 estimate or any other aspect of this form,
including suggestions for reducing completion time, to the Office of Personnel
Management, Retirement Services Publications Team (3206-0170), Washington,
D.C. 20415-3430. The OMB Number 3206-0170 is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is
displayed.
SF 3106 Instructions (page 1)
Revised September 2013

Special Tax Notice Regarding Rollovers
Your refund consists of a taxable portion (any interest payable) and
an after-tax portion (the actual retirement contributions that you paid
into the retirement system). This notice explains how you can
continue to defer federal income tax on the interest payable on your
refund payment from the Federal Employees Retirement System
(FERS) and contains important information you will need before you
decide how to receive your refund.
This notice is provided to you because your refund is eligible for
rollover by you or the Office of Personnel Management (OPM) to
a traditional Individual Retirement Arrangement (IRA), a Roth IRA
or an eligible employer plan. A rollover is a payment by you or
OPM of all or part of your benefit to an eligible employer plan or
IRA. A rollover to a traditional IRA or eligible employer plan allows
you to continue to postpone taxation of that benefit until it is paid to
you. You cannot postpone taxation of the taxable portion of your
refund if you roll it over to a Roth IRA. Your payment cannot be
rolled over to a SIMPLE IRA or a Coverdell Education Savings
Account (formerly known as an education IRA). An "eligible
employer plan" includes a plan qualified under section 401(a) of the
Internal Revenue Code, including a 401(k) plan, profit-sharing plan,
defined benefit plan, stock bonus plan and money purchase plan; a
section 403(a) annuity plan; a section 403(b) tax-sheltered annuity;
and an eligible section 457(b) plan maintained by a governmental
employer (governmental 457 plan).

the taxable portion rolled into a Roth IRA in the year in which the
rollover is made.
If you choose to have your refund PAID TO YOU:
• You will receive 80% of the interest portion (taxable amount) of the
payment, because OPM is required to withhold 20% of that amount
and send it to the IRS as income tax withholding to be credited
against your taxes. You will receive all of your actual retirement
contributions, since taxes have already been paid on this amount.
• The interest portion of your payment will be taxed in the current
year unless you roll it over. If you receive the payment before age
59-1/2, you may have to pay an additional 10% tax.
• You can roll over all or part of the refund payment by paying it to
your traditional IRA, a Roth IRA or to an eligible employer plan
that accepts your rollover within 60 days after you receive the
payment. The amount of the interest portion rolled over will not be
taxed until you take it out of the traditional IRA or the eligible
employer plan. You cannot postpone taxation of amounts rolled into
a Roth IRA, even if you roll it over to a Roth IRA within 60 days.
• If you want to roll over 100% of the payment, you must find other
money to replace the 20% of the taxable portion (interest amount)
that was withheld. If you roll over only the 80% of the interest
amount that you received, you will be taxed on the 20% that was
withheld and that is not rolled over.

An eligible employer plan is not legally required to accept a rollover.
Before you decide to roll over your payment to an employer plan, you
should find out whether the plan accepts rollovers and, if so, the types
of distributions it accepts as a rollover. You should also find out
about any documents that are required to be completed before the
receiving plan will accept a rollover. Even if a plan accepts rollovers,
it might not accept rollovers of certain types of distributions, such as
after-tax amounts. The portion of your refund that represents your
actual retirement contributions, is an after-tax amount. (The interest
payable on this amount is a taxable amount.) If this is the case, you
may wish instead to roll your distribution over to a traditional IRA or
Roth IRA or split your rollover amount between the employer plan in
which you will participate and a traditional or Roth IRA. If an
employer plan accepts your rollover, the plan may restrict subsequent
distributions of the rollover amount or may require your spouse's
consent for any subsequent distribution. A subsequent distribution
from the plan that accepts your rollover may also be subject to
different tax treatment than distributions from OPM. Check with the
administrator of the plan that is to receive your rollover prior to
making the rollover.

Your Right to Waive the 30-Day Notice Period
Generally, neither a direct rollover nor a payment to you can be made
until at least 30 days after your receipt of this notice. Thus, after
receiving this notice, you have at least 30 days to consider whether or
not to have your withdrawal directly rolled over. If you do not wish to
wait until this 30-day notice period ends before forwarding your refund
application to your former agency or OPM, you may waive the notice
period by making an election indicating whether or not you wish to
make a direct rollover.

If you have a Federal Retirement Thrift Savings Plan account, you
may roll over the taxable portion (interest portion) of your refund
into that account. The Thrift Savings Plan (TSP) will not accept
non-taxable monies (the actual retirement contributions that are being
refunded). To accomplish a rollover to the TSP, you will need to
submit form TSP-60 to us. See Part II, Direct Rollover for more
information.

After-tax Contributions. After-tax contributions (your actual retirement
contributions, excluding any interest paid) may be rolled into either a
traditional IRA, a Roth IRA or to certain employer plans that accept
rollovers of the after-tax contributions. The following rules apply:

Summary
There are two ways you may be able to receive a refund that is
eligible for rollover.
1) Your refund payment can be made directly to a traditional or Roth
IRA that you establish or to an eligible employer plan that will
accept it and hold it for your benefit ("DIRECT ROLLOVER"); or
2) The payment can be PAID TO YOU.
If you choose a DIRECT ROLLOVER of your refund:
• The interest portion of your payment (the taxable portion) will not
be taxed in the current year and no income tax will be withheld,
if it is rolled over to a traditional IRA or eligible employer plan.
• The taxable portion of your payment made directly to your Roth
IRA is taxable income in the year in which the rollover is paid.
OPM will not withhold income tax unless you elect that 20% tax be
withheld in item 13 on this form.
• You choose whether your refund payment will be made directly to
your traditional IRA, a Roth IRA or to an eligible employer plan
that accepts your rollover. Your payment cannot be rolled over
to a SIMPLE IRA or a Coverdell Education Savings Account.
• The interest portion of your payment (the taxable portion), if rolled
over to a traditional IRA or eligible employer plan, will be taxed
later when you take it out of the traditional IRA or the eligible
employer plan. Depending on the type of plan, the later distribution
may be subject to different tax treatment than it would be if you
received a taxable distribution from OPM. You must pay tax on

More Information

I. Payments That Can and Cannot Be Rolled Over
Refund payments are "eligible rollover distributions." This means that
they can be rolled over to a traditional IRA, a Roth IRA or to an
eligible employer plan that accepts rollovers. They cannot be rolled
over to a SIMPLE IRA or a Coverdell Education Savings Account.
Both the taxable portion (interest) and the after-tax portion (actual
retirement contributions) can be rolled over.

a) Rollover into a traditional IRA or a Roth IRA. You can roll over
your after-tax contributions to a traditional IRA or Roth IRA either
directly or indirectly. The actual retirement contributions being
refunded to you are after-tax contributions. You do not owe any tax
on this amount. Only the interest portion is taxable.
If you roll over after-tax contributions to a traditional IRA or a Roth
IRA, it is your responsibility to keep track of, and report to the IRS
on the applicable forms, the amount of these after-tax contributions.
This will enable the nontaxable amount of any future distributions
from the traditional IRA to be determined.
Once you roll over your after-tax contributions to a traditional IRA
or a Roth IRA, those amounts CANNOT later be rolled over to an
employer plan.
b) Rollover into an Employer Plan. You can roll over after-tax
contributions to an employer plan using a direct rollover if the other
plan provides separate accounting for amounts rolled over,
including separate accounting for the after-tax employee
contributions and earnings on those contributions. You CANNOT
roll over after-tax contributions to a governmental 457 plan. If you
want to roll over your after-tax contributions to an employer plan
that accepts these rollovers, you cannot have the after-tax
contributions paid to you first. You must instruct OPM to make a
direct rollover on your behalf. Also, you cannot first roll over
after-tax contributions to a traditional or a Roth IRA and then roll
over that amount into an employer plan.
SF 3106 Instructions (page 2)
Revised September 2013

II. Direct Rollover
A DIRECT ROLLOVER is a direct payment of your refund to a
traditional individual retirement arrangement (IRA), a Roth IRA or an
eligible employer plan that will accept it. You can choose a DIRECT
ROLLOVER of all or any portion of your refund, as described in Part I
on the previous page. You are not taxed on the taxable portion of your
payment (interest amount) for which you choose a DIRECT
ROLLOVER to a traditional IRA or eligible employer plan until you
later take it out of the traditional IRA or eligible employer plan. You
are taxed on any taxable portion rolled into a Roth IRA in the year in
which the rollover is made.
No income tax withholding is required for any taxable portion of your
refund for which you choose a DIRECT ROLLOVER to a traditional
IRA or employer plan. You cannot choose a DIRECT ROLLOVER if
your refund payment is less than $200.
DIRECT ROLLOVER to a Traditional IRA or a Roth IRA. You can
open a traditional IRA or a Roth IRA to receive the direct rollover.
If you choose to have your refund paid directly to a traditional IRA
or a Roth IRA, contact an IRA sponsor (usually a financial institution)
to find out how to have your payment made in a direct rollover to a
traditional IRA or a Roth IRA at that institution. If you are unsure of
how to invest your money, you can temporarily establish a traditional
IRA to receive the payment. However, in choosing a traditional IRA,
you may want to make sure that the traditional IRA you choose will
allow you to move all or a part of your payment to another traditional
IRA or Roth IRA at a later date, without penalties or other limitations.
See IRS Publication 590, Individual Retirement Arrangements, for
more information on traditional IRAs and Roth IRAs (including limits
on how often you can roll over between IRAs).
DIRECT ROLLOVER to an Eligible Employer Plan. If you are
employed by a new employer that has an eligible employer plan, and
you want a direct rollover to that plan, ask the plan administrator of
that plan whether it will accept your rollover. An eligible employer
plan is not legally required to accept a rollover. Even if your new
employer's plan does not accept a rollover, you can choose a DIRECT
ROLLOVER to a traditional or Roth IRA. If the employer plan accepts
your rollover, the plan may provide restrictions on the circumstances
under which you may later receive a distribution of the rollover amount
or may require spousal consent to any subsequent distribution. Check
with the plan administrator of that plan before making your decision.
Change in Tax Treatment Resulting from a DIRECT ROLLOVER.
The tax treatment of any payment from the eligible employer plan or
IRA receiving your DIRECT ROLLOVER might be different than if
you received your benefit in a taxable distribution directly from the
Office of Personnel Management (OPM).
Direct Rollover to the Thrift Savings Plan (TSP). If you choose to roll
part or all of the taxable portion of your distribution into your TSP
account, you need to submit form TSP-60, Request for Transfer Into the
TSP, along with your refund application. This form is available on the
internet at www.tsp.gov. Fill out your portion of the form; we will
complete our portion and fax it to the TSP office for processing.
The form must be approved by the Thrift Savings Board and the Board
must notify OPM to transfer the funds.

III. Payment Paid to You
If your payment can be rolled over (see Part I on the previous page) but
the payment is made directly to you, the interest portion is subject to
20% federal income tax withholding (state tax withholding may also
apply). The payment is taxed in the year you receive it unless, within
60 days, you roll it over to an IRA or an eligible employer plan that
accepts rollovers. If you do not roll it over, special tax rules may apply.
Income Tax Withholding:
Mandatory Withholding. If any portion of your payment can be rolled
over under Part I on the previous page and you do not elect to make a
DIRECT ROLLOVER, OPM is required by law to withhold 20% of the
interest portion (taxable amount). This amount is sent to the Internal
Revenue Service (IRS) as federal income tax withholding. For
example, if you can roll over a taxable payment of $10,000, only
$8,000 will be paid to you because OPM must withhold $2,000 as
income tax. However, when you prepare your income tax return for the
year, unless you make a rollover within 60 days (see "Sixty-Day
Rollover Option" below), you must report the full $10,000 as a taxable
payment from OPM. You must report the $2,000 as tax withheld, and it
will be credited against any income tax you owe for the year. There
will be no income tax withholding if your payments for the year are less
than $200.

Sixty-Day Rollover Option. If you receive a payment that can be rolled
over under Part I on the previous page, you can still decide to roll over
all or part of it to a traditional IRA, a Roth IRA or to an eligible
employer plan that accepts rollovers. If you decide to roll it over, you
must contribute the amount of the payment you received to a traditional
IRA or Roth IRA or eligible employer plan within 60 days after you
receive the payment. The portion of your payment that is rolled over
will not be taxed until you take it out of the traditional IRA or the
eligible employer plan.
You can roll over to a traditional IRA, a Roth IRA or to an eligible
employer plan, up to 100% of your payment that can be rolled over
under Part I on the previous page, including an amount equal to the
20% of the taxable portion that was withheld, if you choose to have the
20% withheld from the rollover amount. If you choose to roll over
100%, you must find other money within the 60-day period to
contribute to the traditional IRA or the eligible employer plan, to
replace the 20% that was withheld. On the other hand, if you roll over
only the 80% of the taxable portion that you received, you will be taxed
on the 20% that was withheld.
Example: The taxable portion of your payment that can be rolled over
under Part I on the previous page, is $10,000, and you choose to have it
paid to you. You will receive $8,000, and $2,000 will be sent to the
IRS as income tax withholding. Within 60 days after receiving the
$8,000, you may roll over the entire $10,000 to a traditional IRA or an
eligible employer plan. To do this, you roll over the $8,000 you
received from OPM, and you will have to find $2,000 from other
sources (your savings, a loan, etc.). In this case, the entire $10,000 is
not taxed until you take it out of the traditional IRA or an eligible
employer plan. If you roll over the entire $10,000, when you file your
income tax return you may get a refund of part or all of the $2,000
withheld.
If, on the other hand, you roll over only $8,000, the $2,000 you did not
roll over is taxed in the year it was withheld. When you file your
income tax return, you may get a refund of part of the $2,000 withheld.
(However, any refund is likely to be larger if you roll over the entire
$10,000.)
Additional 10% Tax If You Are under Age 59-1/2. If you receive a
payment before you reach age 59-1/2 and you do not roll it over, then,
in addition to the regular income tax, you may have to pay an extra tax
equal to 10% of the taxable portion of the payment. The additional
10% tax generally does not apply to (1) payments that are paid after
you separate from service with your employer during or after the year
you reach age 55, (2) payments that are paid because you retire due to
disability, (3) payments that are paid directly to the government to
satisfy a Federal tax levy, (4) payments that are paid to an alternate
payee under a qualified domestic relations order, or (5) payments that
do not exceed the amount of your deductible medical expenses. See
IRS Form 5329 for more information on the additional 10% tax.
Additional Tax Information
This notice summarizes only the federal (not state and local) tax rules
that might apply to your payment. The rules described above are
complex and contain many conditions and exceptions that are not
included in this notice. Therefore, you may want to consult with the
IRS or a professional tax advisor before you take a payment of your
refund from OPM. You can find more specific information on the tax
treatment of payments from qualified employer plans in IRS
Publication 575, Pension and Annuity Income, and IRS Publication
590, Individual Retirement Arrangements. For an overview of the tax
consequences of payments from the Civil Service Retirement System
and Federal Employees Retirement System, you can also consult IRS
Publication 721, Tax Guide to U.S. Civil Service Retirement Benefits.
These publications are available from your local IRS office, on the
IRS's website at www.irs.gov, or by calling 1-800-TAX-FORMS.

SF 3106 Instructions (reverse of page 2)
Revised September 2013