RI 25-7 Marital Status Certification Survey

Form Approved:
OMB No. 3206-0033

United States
Office of Personnel Management
Retirement Surveys and Students Branch
1900 E Street NW - Room 2416
Washington, DC 20415-0001

Case name

Case number

Date (mm/dd/yyyy)

(Show any address change next to your address.)

Marital Status Certification Survey
You must complete and return this form within 30 days after the date shown above. The form must be signed and
dated. Please also provide your daytime telephone number.
Please read the back of this form before completing. Check only the item that applies to you. Please enter the month, day
and year in the space provided.
I have never remarried.
I remarried before I reached age 55 (this includes civil, religious and common law marriages). Date (mm/dd/yyyy)
The date of my remarriage is

I remarried before I reached age 55. However, I was married to the person named above for a
full 30 years before his/her date of death. We were married on.


Date (mm/dd/yyyy)

I remarried before I reached age 55. This marriage has since ended. The dates my marriage began and ended are
indicated below. Please provide a copy of the document showing the date the marriage ended by death, divorce,
or annulment.
Date of remarriage (mm/dd/yyyy)

Date the marriage ended (mm/dd/yyyy)

Warning: We may verify your marital status through a computer match with other Federal agencies. Any intentionally false
or misleading statement, certification, or response you provide 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 USC 1001).
I certify that all information provided on this form is true and correct to the best of my knowledge and belief.
Signature

Daytime telephone number

Previous editions are not usable.

Date (mm/dd/yyyy)

Email address

RI 25-7
Revised November 2017

Who Needs to Complete This Form?
You must complete and return this form in the envelope enclosed or fax your response.
This form is sent annually to verify your eligibility to continue receiving a survivor annuity. By law, you may continue receiving
this annuity only as long as you do not remarry before your 55th birthday unless you were married to the decedent for at least 30
years before his or her death. If you remarried and that marriage ended, please provide a copy of the document showing the date
the marriage ended by death, divorce or annulment. You are responsible for notifying us immediately of your remarriage.
Failure to notify us immediately will result in an overpayment of annuity. You will be held liable for all annuity paid to you
after the remarriage.

How to Respond to This Survey
You may return this form to the U.S. Office of Personnel Management (OPM):
in the enclosed return envelope, or
fax to (202) 606-0022 or (202) 606-2829.
The mailing address for Retirement Surveys and Students Branch is shown on the front of this survey form.

Information on Common Law (Mutual Consent) Marriage
If you live in a state that recognizes a common law (mutual consent) marriage, we must treat it the same as a marriage by a civil
or religious ceremony.
Need Help?
If you help, please contact our Washington, DC office at (202) 606-0249 or write to us at the address on the front of this survey
form. For general questions you may contact our Retirement Information Office toll free at 1-888-767-6738 from 7:30 AM to
7:45 PM, Eastern Time.

Privacy Act Statement

Separate PAS Header

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 requested on this form by Title 5 U.S. Code Sections 8341, 8442, and 8445 to authorize a survivor annuity to eligible
widows, widowers, and former spouses of former Federal employees. Purpose: OPM takes appropriate action based on the responses to determine whether
to continue the survivor annuity. Routine Uses: The information requested on this form may be shared externally as a "routine use" to other Federal
agencies and third-parties when it is necessary to process your designation. For example, matching programs, with national, state, local or other charitable or
social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination 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. Consequences of Failure To Provide Information: If this information is not
collected, OPM could continue payments to individuals who are no longer eligible.

Public Burden Statement

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We estimate providing this information takes an average 15 minutes per response, including the time for reviewing instructions, gathering the needed data,
and reviewing the requested information. Send comments regarding our estimate or any other aspect of this form, including suggestions for the reducing
completion time, to the U.S. Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0033), Washington, DC 20415-0001.
The OMB Number 3206-0033 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Reverse of RI 25-7
Revised November 2017