RI 25-41 Initial Certification of Full-Time School Attendance

Form Approved:
OMB No. 3206-0099

United States
Office of Personnel Management
Retirement Operations
PO Box 45
Boyers, PA 16017-0045

Initial Certification of
Full-Time School Attendance
Reference
Date (mm/dd/yyyy)
Claim number

(suffix)

CSF
Name of deceased employee
Name of child
Date of death (mm/dd/yyyy)

On roll?
Yes

No

The Application for Death Benefits shows that the child named above, a survivor of a Federal employee or annuitant, is (or soon will be) age
18. After reaching age 18, a child is eligible for a survivor annuity only if unmarried and (1) a full-time student in an accredited school or
(2) incapacitated for self-support because of a physical or mental disability that began before age 18.
If a child is unmarried and incapacitated for self-support because of a mental or physical disability, do not fill in the other side of this form.
Instead, return the form to us with a doctor's certificate describing the nature and extent of the child's disability. After we review the
documentation of the disability, we will write to you about the child's eligibility for benefits.
If the child is unmarried and a full-time student, you should complete Part A on the other side of this form; a school official (the principal,
administrator, registrar, etc.) should complete Part B, and you should return the completed form to us promptly. If the child's school year
was not in session on the date of death (shown above), have the school official complete Part B for the last school year attended.
Send the completed form to:
U.S. Office of Personnel Management
Retirement Operations Center
Attn: Survivor Claims
PO Box 45
Boyers, PA 16017
Privacy Act Statement
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to
collect the information on this form by 5 U.S.C. Chapter 83 (Civil Service Retirement) and the 5 U.S.C. Chapter 84 (Federal Employees' Retirement). OPM is authorized to
collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008). Purpose: OPM is
requesting this information in order to determine if the child is eligible to receive survivor benefits. Routine Uses: The information requested on this form may be shared
externally as a "routine use" to other Federal, state, or local agencies and organizations for determination or continuation of benefits from OPM, or to report income for tax
purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a violation or potential violation of civil or criminal law. A complete
list of routine uses can be found in the OPM/Central 1 Civil Service Retirement and Insurance Records system of records notice, available at www.opm.gov/privacy.
Consequences of Failure to Provide Information: Providing the information is voluntary. However, failure to provide this information may delay or prevent OPM from
being able to determine whether unmarried dependent children (between age 18 and 22 years of age) are eligible to receive survivor benefits.

Public Burden Statement
We estimate this form takes an average 90 minutes per response 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 (3206-0099), Washington, DC 20415-0001. The OMB Number 3206-0099 is currently valid. OPM may not collect this
information, and you are not required to respond, unless this number is displayed.

This Space is For the Use of the Office of Personnel Management Only.
Remarks:

Approved

Inspector

Previous editions are not usable

Not Approved Because
Less than full-time school attendance
Not in school
Over 5-month break in attendance
Married
Non-recognized school
Other (specify):
Date (mm/dd/yyyy)

Call up (M-Card) processed

Benefits specialist
Date (mm/dd/yyyy)
RI 25-41
Revised February 2018

Part A

To be completed by the payee (the person who expects to receive benefits for the student).
Read the reverse side this form before answering the questions below; give full information; typewrite or print in ink.

1.

Student's name (first, middle, last)

4.

Is this student married?

No
Current
Status

2.

Student's date of birth (mm/dd/yyyy)

Payee
Signs
Here

Student's social security number

Date of marriage (mm/dd/yyyy)

 If "Yes", show the date at right, sign item 7 of this part, and return
this form. (It is not necessary to complete the rest of the form.)

Yes
5.

Is this student married?

6.

After the end of the school year, does the student intend to continue as a full-time student with less than a 5-month break between school years?

No

 If "No", show the date at right, the student last attended

Last date school was attended (mm/dd/yyyy)

school on a full-time basis.

Yes

Yes - If "Yes", give the details in items 6a and 6b.
Future
Plans

3.

No - If "No", go to item 7.

Undecided - If "Undecided", go to item 7.
6a.

Enter the date (or approximate
date) the next school year or
term begins after current
enrollment (mm/dd/yyyy)

6b.

7.

I certify that all information given in this certification is true and correct to the best of my knowledge and belief. I understand that I must immediately
notify the Office of Personnel Management (OPM) if the student transfers to another school, discontinues school attendance, reduces attendance to less
than full-time, marries, or dies. I further agree to return all overpayments of student benefits, including overpayments that may be erroneously made after
I notify OPM of any terminating event. I authorize the appropriate school official to verify the student's school attendance status to OPM in the manner
requested by that agency.

Signature of payee

Complete name and mailing address (including ZIP code) of the educational institution the student will attend
next year.

E-mail address

Daytime telephone number

Date (mm/dd/yyyy)

Part B
To be completed by an official of the educational institution for the school year ____________________ to ____________________.
(month/year)
1.

Is/was the student enrolled in and attending a
full-time course of resident study or training
(not correspondence) for the period requested?

4.

Check the type of educational institution:

Yes

Actual date the student started school for the
school year indicated above (mm/dd/yyyy)

3.

Official ending date of the school year (mm/dd/yyyy)

5.

Show the complete name and mailing address
(including the ZIP code) of the educational institution.

No

High school
Trade school
Technical institute
Vocational institute
6.

2.

(month/year)

Junior/community college
College or university
Other (specify)

Show the total school hours per week:

a. If college or equivalent, show credit hours: _______________
b. If high school or equivalent, show actual clock hours: _______________
c. If in a work-study program sponsored by the school,

 show hours at work: _______________
 show hours at school: _______________
Complete items 7 and 8 below if your institution is not a state college, state university, or public high school.
7.

Show the complete name and address (including ZIP code) of the organization
which accredits, licenses, or otherwise recognizes the school.

8.

If the educational institution is licensed, show:
a. Current license number:

I certify that the information given in regard to requested school enrollment of the above-named student is true and
correct to the best of my knowledge and belief.

School
Official
Signs
Here

Signature of principal, administrator, registrar, etc.

Telephone number

Title

Date (mm/dd/yyyy)

b. Expiration date of current license
(mm/dd/yyyy)

Warning: Any intentionally false statement, willful concealment of 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)
Reverse of RI 25-41
Revised February 2018