Form Exchange Form 1450 Exchange Form 1450 Annuity Application

ANNUITY APPLICATION
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)

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AGENCY DISCLOSURE NOTICE

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The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate,
Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0702-XXXX). Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.

Responses should be sent to your local Exchange HR Representative or to the Treasury Benefit department at the Army and Air Force
Exchange Service, 3911 South Walton Walker Blvd., Dallas, TX 75236-1598.
PRIVACY ACT STATEMENT

AUTHORITY: Title 10 U.S.C. 3013, “Secretary of the Army”; Title 10 U.S.C. 8013, “Secretary of the Air Force”; Title 42 U.S.C. 659,
“Consent by United States to income withholding, garnishment, and similar proceeding for enforcement of child support and alimony
obligations”; 31 CFR 285.11, “Administrative Wage Garnishment”; DoD Directive 7000.14-R, Volume 13 and 16, “DoD Financial
Management Regulation”; Department of Defense Instruction (DoDI) 1400.25, Volume 1408, “DoD Civilian Personnel Management
System: Insurances and Annuities for Nonappropriated Fund (NAF) Employees”; Army Regulation 215-8/AFI 34-211(I), “Army and Air
Force Exchange Service Operations”; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): Information collected is to provide the basis for computing civilian/retiree/survivor pay deductions and for

processing of insurance benefits chosen by active Exchange associates.

ROUTINE USE(S): Your records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding DoD “Blanket

Routine Uses” published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Information may be disclosed to
former spouses and/or survivors, to federal, state, or local child support agencies for purposes of assisting the agencies in the discharge of
their responsibilities under federal and state law.
DISCLOSURE: Voluntary, however, failure to provide all the requested information may result in the denial of your application for

benefits.

SYSTEM OF RECORD NOTICE: AAFES 0703.07 “Employee Pay System
Records”; http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570129/aafes-

070307.aspx

AAFES 0903.06 “Personnel Management Information System”;

http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570130/aafes-090306.aspx

INSTRUCTIONS

The following application is completed by an active Exchange employee once their request for retirement has been approved.
The FACT sheet on the second page of the application should be reviewed before information is provided Questions should be addressed
to the Human Resource (HR) representative or to the Headquarters Benefit Department.
Employee personal information is collected on the first page of the application.
Section A collects the employee’s annuity choices and survivor’s designation.
Section B is answered and provides information on any previous workers’ compensation claims. This information may affect annuity
payments.
Section C is completed by employees who have served in the Military.
Section D should be signed and witnessed by the HR representative.
Section E should be signed by the employee if hired prior to 1967, their survivors and spouse. This section should be witnessed.
Questions or issues completing the enrollment form should be first directed to the employee’s HR representative or to the Exchange’s
Human Resource Support Center at 800-508-8466.

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