Form RI 20-63 RI 20-63 Survivor Annuity Election for a Spouse

Form approved:
0MB number: 3206-0174

Survivor Annuity Election for a Spouse
Your full name (Please print)

Your claim number

CSA

I

~Please Provide the Following Information About Your Spouse
Spouse's full name (Please print)

Spouse's Social Security Number

Date of marriage (Your election must be received within two years after this
date)

Spouse's date of birth

Election: I elect a reduced annuity to provide a survivor annuity for my spouse named above. I have read and understand the information
in the accompanying letter. I understand that this election terminates if my marriage ends in divorce, annulment, or the death of my
spouse. Pamphlets are available on https://www.servicesonline.opm.gov.

(Choose one of the following as a base for computing the survivor annuity)

E]

I elect the maximum survivor annuity benefit.
I elect a survivor annuity benefit equal to

$_ _ _ _ _ _ _ _ _ per month. (Specify a whole dollar amount.

If my marriage terminates and I want to provide a survivor benefit for a former spouse, I understand that I must file a specific
written election with OPM within 2 years after the date of termination of my marriage.

Important: You Cannot Revoke This Election.
Your signature (Do not print)

Date

Email address

Daytime telephone number

To elect no survivor benefit for your spouse, write your initials in the block provided and sign your name below the block
I have read the enclosed information and have decided not to provide a survivor benefit. I have signed below.
Your signature electing no survivor benefits (Do not print)
Date

Privacy Act Statement
Title 5, U.S. Code, authorizes solicitation of this information. The data you furnish on the election letter will be used to determine your eligibility to receive
a reduced annuity and to give a survivor annuity to your spouse. 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, 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. Failure to supply all of the requested information may result in our inability to reduce your annuity
for your spouse.
We need your spouse's Social Security Number so that it may be used as an individual identifier in the Civil Service Retirement System. Executive Order
9397 (November 22, 1943) authorizes the use of the Social Security Number.

Public Burden Statement
We estimate the election takes an average 45 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 U.S. Office of Personnel Management, Retirement Services Publications Team (3206-0174), Washington, DC 20415-0001. The
0MB Number, 3206-0174, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Previous editions are not usable.

RI 20-63
Revised August 2016