Form SF2812 Report of Withholdings and Contributions for Health Bene

Form Approved
OMB 3206-0262

Report of Withholdings and Contributions for Health Benefits,
Life Insurance and Retirement
FROM: Address (including Department, Bureau, Location, and ZIP Code)

Interagency Report
No. 1064-OPM-AR

Payroll Office Number

Report Number

Month reported on Statement of Transactions

Date Payroll Paid

PAY PERIOD

From

To

Telephone number (including area code)

To: OFFICE OF PERSONNEL MANAGEMENT
ATTN: FUNDS MANAGEMENT
POST OFFICE BOX 582
WASHINGTON, DC 20044-0582
Benefit Category
Withholdings

I certify that the items listed herein are correct and the amount is available to
be credited to the OPM receipt account.

Signature of authorized Administrative or Certifying Officer Date

Contributions

Total

LIFE INSURANCE
Basic Life
Standard - Option A
Additional - Option B
Family - Option C
Post-Retirement
Total Life Insurance
HEALTH BENEFITS
Regular
Temporary Continuation of
Coverage (TCC) - P.L. 100-654
Total Health Benefits
RETIREMENT
CSRS
All Categories1
Salary Offset - Reemployed
Annuitants
Military and Civilian Service Credit
FERS
Regular
Military Reserve Technician
Special 2
Salary Offset - Reemployed
Annuitants
Military Deposit
FERS - RAE
Regular - RAE
Military Reserve Technician - RAE
Special - RAE 3
Salary Offset - Reemployed
Annuitants - RAE
Military Deposit - RAE
FERS - FRAE
Regular - FRAE
Military Reserve Technician - FRAE
Special - FRAE 4
Salary Offset - Reemployed
Annuitants - FRAE
Military Deposit - FRAE
Total Retirement
Grand Total
1

Employees with CPDF Retirement Codes of 1, 6, C, E, R or T.
Employees with CPDF Retirement Codes of L, M or O.
3
Employees with CPDF Retirement Codes of LR, MR or OR.
2

4

Employees with CPDF Retirement Codes of LF, MF or OF.
Public Burden Statement

We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments
regarding our time estimate or any other aspect of this form, including suggestions for reducing completing time, to the Office of Personnel Management, Funds Management, P.O. Box 582,
Washington, DC 2044. The OMB Number 3206-0262 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll
Offices

Standard Form 2812
This form may be locally reproduced

Revised October 2014