RI 38-031_2017_03 Marked Up version

United States
Office of Personnel Management
Check Loss
PO Box 7815
Washington, DC 20044-7815

Form Approved:
OMB number 3206-0187

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Highlighted text indicates updated content.

We Need Information About Your Missing Payment
You may report a missing annuity or survivor annuity payment on the internet at apps.opm.gov/retire/payment/missing_pay.cfm. Or,
use page 2 of this form to report that you have not received a payment authorized by the retirement system, that was lost, stolen,
destroyed, or if a direct deposit was not properly credited to your account at a financial organization. If you wish to file a report of
nonreceipt of payment, please complete page 2 of this form. Remember to sign it and return it without delay to the address shown at the
top of this page. The Office of Personnel Management (OPM) will send your report to the Department of the Treasury, which maintains
all records on issued payments, so that corrective action may be taken on your behalf.

The retirement system will send your report to the Department of the Treasury as quickly as possible after receipt of the completed form.
If your payment was a check, the Department of the Treasury will determine whether it has been cashed. If it has not been cashed, a
replacement check will be sent to you. If it has been cashed, the Department of the Treasury will contact you with further instructions.

If your payment was by direct deposit, you need to contact your financial organization before you complete this form. If your financial
organization cannot help you, complete Parts A, B, and C and sign the certification. The Treasury will trace the payment and contact you
with further instructions.

You must return this notice to us. We cannot take any action until you complete the form on page 2 of this notice and return the
information to us. If you need assistance in completing this form, telephone OPM's Retirement Information Office at 1-888-767-6738.
Our hours are 7:30 a.m. to 7:45 p.m. Eastern time.

Retirement Operations

Reports of lost or stolen checks outnumber reports about not receiving direct deposits by one hundred to one.
Get direct deposit -- know your payments are safe and sure.

Privacy Act Statement

Public Burden Statement

Title 5, U.S. Code, Chapter 83, Civil Service Retirement and Chapter 84, Federal Employees Retirement System
authorize solicitation of this information. The data you furnish will be used to submit a claim for your missing
payment. This 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 to determine and issue benefits under their programs 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 as an individual identifier to distinguish between people with the same or
similar names. Failure to furnish the requested information may result in OPM being unable to assist you.

We estimate this form usually takes 10 minutes per response to complete;
on occasion it may take up to 30 minutes, 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
(3206-0187), Washington, DC 20415-0001. The OMB number, 3206-0187
is currently valid. OPM may not collect this information, and you are not
required to respond, unless this number is displayed.

Previous editions are usable.

RI 38-31
Revised March 2017

A. Payee Information and Statement
The retirement payment described below has not been received
or has been lost.

If the address to the left should be changed and you have not
notified the Office of Personnel Management, write your
correct address below.

Name of person to whom payment was sent

Name

Street address, including apt. no. to which check was sent

Street address, including apt. no.

City

State

The missing payment is

ZIP Code

A direct deposit to a financial organization

A check

City

State

ZIP Code

Have your financial organization verify nonreceipt by completing Part C below.
Did you receive the missing check?

Yes

No

Did you sign your name on the check before it was missing?

Yes

No

B. Description of the Missing Payment - Answer question 1 below and follow the instructions beside the block you check.
1. The missing payment is (check one block).
Annuity/alternative annuity
(Answer questions 2, 3, and 4 below.)

Death benefit lump sum payment
(Answer questions 2, 3, 4, 5, 6, and 7 below.)

Survivor annuity
(Answer questions 2, 3, 4, and 5 below.)

Refund of retirement deductions
(Answer questions 3, 4, 8, and 9 below.)

2. Claim number (CSA is an annuity claim; CSF is a survivor annuity or a death benefit lump sum payment claim. Enter your claim number in the blank that applies to
you.)

CSA

CSF

3. Approximate date of payment (mm/dd/yyyy)

4. Amount of payment

$
5. Full name of the deceased former employee (last, first, middle)

6. Former employee's Social Security Number

7. Former employee's date of birth (mm/dd/yyyy)

8. Your Social Security Number

9. Your date of birth (mm/dd/yyyy)

C. Description of Direct Deposit - If your payment is being deposited directly to a financial organization, complete this part.
Financial organization routing

Depositor account number

Type of account (check one)
Checking

Savings

Financial organization name and address

Please review the above responses to be sure you have provided all the information requested on the line you checked in item 1.

Warning: If, after you receive a replacement payment as a result of this claim, we determine that you cashed or received the benefit
of both the original and any replacement payments, we will take prompt action to recover the amount of the overpayment
from you.
Certification - I certify that the payment described was not received or was received and is missing.
Signature

PRINT

Telephone number

SAVE

Date (mm/dd/yyyy)

CLEAR
Page 2, RI 38-31
Revised March 2017