CFC Paper Retirement Enrollment

A ll Paper Pledge Forms must be post marked by Online pledges are accepted through

January 12, 2018. Please use red or black ink. January 12, 2018 or by visiting www.opm.gov/showsomelovecfc

Primary Email Address:

Secondary Email Address:

First Name:

Last Name:

Retiree Type:

 Military  Civilian

Home Zip code: _ _ _ _ _-_ _ _ _

 I’m located in a non-US or Territory without a zip-code

Home Address:

City:

State:

Zip code:

SSN: Required if elect Annuity

_ _ _-_ _ -_ _ _ _

DESIGNATED PLEDGE: To designate to one or more Charities or Federated groups, fill in the Charity code and dollar amount for each organization. If you would like to donate to more than 5 Charities, please visit www.opm.gov/showsomelovecfc to complete an online pledge or attach another copy of this form and label your forms 1 of X; 2 of X. The Total Annual Contribution amount should appear on copy 1 of X. The minimum donation is $1 per charity.

Charity CFC Code					Annual Amount
					$
					$
					S
					$
					$
Total Annual Contribution: $_ _ _ _. _ _

Allotment Source	Per Deduction Amount	INTERVAL
Annuity 	$	 Monthly x12
Check 	N/A	 One Time

1. Check Information: Make checks payable to: Combined Federal Campaign (Please attach checks to this Pledge Form).

Keep a copy of this form before sending it to:

CFC Processing Center, P.O. BOX 7820 Madison, WI 53707-7820.

CFC organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via this pledge card.

AUTHORIZATION

If I chose annuity reduction as my payment source, I hereby authorize any agency of the United States Government from which I may be retired during 2018 to deduct the amount(s) shown above from my annuity each payment period during the calendar year 2018. These deductions will start with the first annuity payment period following January 15, 2018 and ending with the last allotment period that includes January 15 of the following year. I authorize the Government to pay the amounts deducted to the Combined Federal Campaign. I understand that this authorization may be revoked by me in writing at any time before it expires. I also acknowledge that I have the right to receive a notification if the amount(s) scheduled to be transferred differ(s) from the amount(s) displayed above.

 Information Release: By checking this box I authorize the CFC to release my contact information to the Charity(ies) designated above.

_{signature Date}

Federal Retirees Only OPM 1654-B

Combined Federal Campaign Privacy Act Statement

Pursuant to 5 U.S. C. 522a(e)(3), this Privacy Act Statement informs you why OPM is requesting information on this form.

AUTHORITY: OPM is authorized to collect the information on this form based upon the authority provided in Executive Order (EO) 12353 (March 23, 1982), as amended by EO 13743 (October 13, 2016), and 5 CFR 950 (January 1, 2017). In addition, Executive Order 9397 (November 22, 1943), as amended by EO 13478 (November 18, 2008), permits us to collect your Social Security Number (SSN).

PURPOSE: The information you provide is primarily collected and used by OPM to accurately receive, process, acknowledge, and account for your donation to the Combined Federal Campaign (CFC); and to make payments to the charitable organizations to which you choose to donate.

ROUTINE USES: The information we collect from you may be disclosed as a “routine use” to your retirement service (e.g., OPM Retirement Services or the Defense Finance and Accounting Services Retiree Pay), if you have chosen to make a recurring gift via a deduction from your annuity; or to your credit card company, bank, or other financial institution, for a one-time or recurring gift (using the CFC’s online option) via credit card, electronic check, or automatic deduction from your financial account. With your authorization, we may also share the information you provide to us with local, national, or international charitable organizations or federations. In addition, we may share your information as a “routine use” with other external entities, such as law enforcement or state and federal tax authorities, when the disclosure is necessary to investigate a violation or potential violation of civil or criminal law. A complete list of routine uses can be found in the system of records notice for OPM 20, National CFC System.

CONSEQUENCES OF FAILING TO PROVIDE INFORMATION: Providing this information, including your SSN, is voluntary; however, without your signature and all of the information requested, it may not be possible for us to make this gift on your behalf, and we may suspend this pledge. In addition, if you do not provide any of the requested information, we may not be able to process your request for an annuity deduction by your retirement service. If you are making a one-time, lump-sum gift and, therefore, not using the annuity deduction method of payment, you are not required to furnish your SSN.

Individuals may pledge online at www.opm.gov/showsomelovecfc and may contact the CFC Help Desk at (Toll Free) 800-797-0098 or (Local/International) 608-237-4898 (Monday through Friday from 8 a.m. until 6 p.m. CST) with questions about the pledge process or contact us at https://cfcgiving.opm.gov/contact.

Public Burden Statement

We think providing this information takes an average of 30 minutes per response to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed information collection title. Send comments regarding our estimate or any other aspect of the information collection, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), OPM Forms Officer (3206-NEW), Washington, D.C. 20415-7900. The OMB number 3206-NEW is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.