Form Exchange Form 1450 Exchange Form 1450 Annuity Application

OMB NO. 0702-0139
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Army and Air Force Exchange Service (AAFES)
ANNUITY APPLICATION
AGENCY DISCLOSURE NOTICE

PRIVACY ACT STATEMENT

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The public reporting burden for this collection of information, 0702-0139, is estimated to average 15 minutes
per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at [email protected]. Respondents should
be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB control number.

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AUTHORITY: 10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 9013, Secretary of the Air Force; 42 U.S.C.
659, Consent by United States to Income Withholding, Garnishment, and Similar Proceedings for Enforcement
of Child Support and Alimony Obligations; 31 CFR 285.11, Administrative Wage Garnishment; DoD
Directive 7000.14-R, DoD Financial Management Regulation; DoD Instruction 1400.25, Volume 1408, DoD
Civilian Personnel Management System: Insurance and Annuities for Nonappropriated Fund (NAF)
Employees; Army Regulation 215-8/AFI 34-211(I), Army and Air Force Exchange Service Operations; and
E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSES: To provide adequate information for Insurance Providers under contract
with AAFES for provision of timely health care services to AAFES employees and to designate
specifics on life insurance beneficiaries and annuities.

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ROUTINE USES: Records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3)
regarding DoD “Blanket Routine Uses” published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Information may be released to
former spouses and/or survivors, to Federal, State, or Local Child Support agencies for purposes of
assisting in discharge of their responsibilities under Federal and State law.

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DISCLOSURE: Voluntary, however, failure to provide ithe requested nformation may result in the denial of
your application for benefits.

A copy of the Privacy Impact Assessment (PIA) for the collection of information may be located at https://www.aafes.com/aboutexchange/public-affairs/FOIA/assessments.htm

SYSTEM OF RECORD NOTICE (SORN): AAFES 703.07 "Employee Pay System Reocrds" may be viewed at http://
dpclddefense.gov/Privacy/SORNsIndex/?Page=9

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Army and Air Force Exchange Service (AAFES)
ANNUITY APPLICATION

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DEFINITION AND FACTS OF ANNUITIES
ANNUITY WITHOUT SURVIVOR BENEFITS
If you choose this form of annuity, you must indicate by checking the block alongside "Annuity Without Survivor Benefit" in Section A.
If you are married, your spouse will not be paid a survivor annuity after your death. If you are married at the time of retirement and
choose this form of annuity you may not change this election at a later date.

ANNUITY WITH SURVIVOR BENEFITS
If you are married:

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(a) If you choose this type of annuity you will receive a reduced annuity in order to provide a survivor annuity to your spouse to
whom you were married at the time of your retirement. (See your Retirement Plan Booklet for information about the amount of
reduction, and provisions concerning payment of a survivor annuity after your death.) To indicate your desire to provide a survivor
annuity, check the block in Section A alongside "Annuity With Survivor Benefit," insert the portion of your annuity to be used as a base
for the survivor annuity if other than 100% and complete the remaining applicable parts of Section A.
(b) At the time you make this election, and the marriage is subsequently terminated by death of the spouse, or by divorce or
annulment, the reduction in your annuity (to provide a survivor annuity) may be discontinued, but such discontinuance will be made
only if you submit a written request for discontinuance together with proof of termination of the marriage. Under all other
circumstances, the reduction will continue during your lifetime.

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(c) If you are separated with a disability annuity, you must use all of your disability annuity as the base amount for the survivor benefit.
(d) If you are an EMP employee, you must use all or none of your annuity payable under the Supplemental Plan and may use all or a
portion of your annuity payable under the Basic Plan as the base amount for a survivor benefit.
(e) If you are not an EMP employee, you may choose all or any portion of your lifetime annuity as the base amount for your spouse's
survivor annuity.
(f) The Nonselection of Survivor Annuity portion of this form identifies spouse's acknowledgment he/she understands the spouse
election of less than maximum benefit of survival protection.
If you are not married:

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(a) You may elect to receive a reduced annuity during your lifetime in order to provide a survivor annuity to the person(s) named
having an insurable interest. The survivor annuity will begin upon your death and end when such named person(s) die(s). You may
choose this form of annuity with respect to all or a portion of your lifetime annuity payable under the Basic Plan. If you are receiving a
disability annuity, this option is not available. This provision is also not available with respect to that portion of any annuity which may
be provided under the Supplemental Plan.
(b) You must specify the name, relationship and date of birth of the person(s) you wish to receive the Survivor Benefit upon your
death. If you have two or more children, you may name any or all of them. If you name someone other than your children, you may
name only one person.
(c) If you make this selection, the annuity payable to you will be reduced as explained in the current Retirement Plan Booklet.

(d) The survivor annuity to the designated survivor(s), if all those survive who were living on the date the retirement annuity becomes
payable, will be 55% of the base amount of your reduced annuity.

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(e) If two or more children have been designated by name, the survivor annuity will be proportionately reduced upon the death of one
or more of those designated who were living on the date your retirement annuity becomes payable, whether such death occurs before
or after your death.
(f) Refer to your Retirement Plan Booklet for information concerning provisions for discontinuance of the election of a survivor annuity
to a child or children, or other named person(s) having an insurable interest in order to elect a surviving spouse annuity on marriage or
remarriage after retirement.
(g) You may use all or a portion of you annuity payable under the Basic Plan as the base amount for a survivor benefit.

EFFECT OF PRIOR ELECTION OF CONTINGENT ANNUITANT OPTION
Any previous election by you of the contingent annuitant option is revoked and is superseded by the election herein of an annuity with
or without survivor benefits.

OVERPAYMENT OF ANNUITY EITHER WITH OR WITHOUT SURVIVOR BENEFITS OR DISABILITY ANNUITY
In the event of overpayment of an annuity either with or without survivor benefits or disability annuity, it will be required of the annuitant
to repay the determined amount of overpayment. Failure to make such repayment will result in a proportionate reduction of the monthly
annuity until such time as the overpayment has been satisfied.

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Army and Air Force Exchange Service (AAFES)  
ANNUITY APPLICATION ‐ Instructions 

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An Annuity is an annual income in a specified amount.  For the purposes of this form, it is the same thing 
as a pension.  The AAFES annuity referred to on this form is described in the AAFES Retirement Booklet, 
Form A027000 on the Forms/Pubs website.  After an employee retires, this form is used by AAFES 
Treasury Benefits when calculating the employee’s pension.  Annuities can be complex.  If you have 
questions about how AAFES annuities are calculated or paid, and whether to choose a survivor benefit, 
please read the AAFES Retirement Booklet, Form A027000 on the Forms/Pubs website.  You may also 
contact AAFES Human Resources Support Center for assistance at 214‐312‐6190 or [email protected].    
The following instructions are provided as guidance for completing the following form.   

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1. Please read the Agency Disclosure Notice, Privacy Act Statement, and the Definition and Facts of
Annuities on the previous pages prior to continuing.   If you have any questions, please contact
AAFES Human Resources Support Center at 214‐312‐6190 or [email protected].
2. Please provide all personal information at the top of the form where requested.  Your Social
Security Number is required to locate all pertinent information for your annuity.
3. SECTION A:  You, your spouse (if required), and the Survivor (if chosen) will complete this
section of the form.   Please be certain to check the Annuity options defined on the Definition
and Facts of Annuities page.
a. Please indicate if your retirement has been approved for reasons of disability (choose
Disability) or not (Choose Retirement).  If you select Disability, you must provide Human
Resources with a completed AAFES Form 1700‐006 entitled Attending Physician’s
Statement.  This form is available on the AAFES Portal under Forms/Pubs or from your
local HR department.

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b. Please select whether you wish your annuity to be “with” or “without” Survivor
Benefits.

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i. If “With” Survivor Benefit is selected:  If you wish to have the maximum amount
of your annuity as the base for the survivor annuity, do not enter a percentage
in this section; it will default to 100%. If you wish only a portion of your annuity
as the base for the survivor annuity, provide the desired percentage. If married,
your spouse must sign in front of a witness that you have chosen the option of
less than the maximum annuity survivor benefit.   Your spouse must complete
the acknowledgement by placing your name in the space provided.  The witness
to your spouse’s signature must sign in the space provided.

ii. If you choose “With” Survivor Benefits, you must complete the area with the
survivor’s information: name, address, relationship to you, citizen of the U.S. or
not, date of birth and SSN.  The survivor must sign this portion of the form.

iii. If “Without” Survivor Benefits is selected and you are married, your spouse
must sign before a witness in the designated space on the form.  This is their
acknowledgment they will not be paid a survivor annuity after your death.  Your
spouse must complete the acknowledgement by placing your name in the space

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provided.  The witness to your spouse’s signature must sign in the space 
provided.    
4. SECTION B:  Please respond if you have ever filed a Workers’ Compensation Claim with AAFES
and if the claim is still open.  Workers’ Compensation payments may affect the amount
calculated for your annuity.  You must sign this portion of the form in front a witness.
5. SECTION C:  Please respond if you have had previous Military Service.  If you answer “YES”
provide the branch of service, your serial number, the dates of service, and whether or not you
were honorably discharged.  You will also need to provide a Yes or No response to questions
regarding military disability or retirement.  This information may affect your AAFES annuity.

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6. SECTION D:  Please read Section D and sign in front of a witness.  If you have any questions on
the certification, please contact AAFES Human Resources Support Center before signing.
7. SECTION E:  ONLY complete this section if you were an AAFES employee before 1967.
Signatures include yourself acknowledging understanding of the release clause, your chosen
Survivor, and your spouse.  A witness must sign each signature acknowledging they witnessed
your signature.

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8. Once you have completed the form and obtained all signatures, including witnesses, attached
any required documents and forward to the Headquarters Human Resources Support Center at
3911 south Walton Walker Blvd., Dallas TX 75236 or to your local HR Representative.

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9. If you submit an incomplete form to Human Resources, or submit a form without the required
attachments, your retirement payments may be delayed.

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Army and Air Force Exchange Service (AAFES)
ANNUITY APPLICATION

OMB NO. 0702-0139
OMB approval expires

MMM DD, YYYY
Before completing, please read the Agency Disclosure Notice, Privacy Act Statement, Instructions, and Definitions of Annuities on the previous pages before completing.
Questions should be directed to the AAFES Human Resources Support Center at 214-312-6190 or [email protected].
PERSONAL INFORMATION to be completed by employee
MEMBER’S NAME (Last, First, MI)
DATE OF BIRTH (MM DD, YYYY)
SOCIAL SECURITY NUMBER
SEX
MALE
FEMALE
HOME ADDRESS (Number and Street, City, ST ZIP Code)

MARITAL STATUS

MARRIED

UNMARRIED (Includes single, widowed and divorced)

SECTION A – ELECTION OF ANNUITY (Completed by employee)
Please choose your Annuity Choice (refer to page two for facts pertaining to each type of annuity):

*Non-selection of Maximum Survivor Annuity Acknowledgment by Spouse

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DISABILITY ANNUITY (Requires an Attending Physician’s Statement to be attached to form when submitting)
RETIREMENT ANNUITY
ANNUITY WITHOUT SURVIVOR BENEFITS*
ANNUITY WITH SURVIVOR BENEFIT
BASIC PLAN (ALL participants must complete)
______% of Annuity to be used as base for the base for the survivor annuity if under 100%
SUPPLMENTAL PLAN (EMP only)
If you chose ANNUITY WITH SURVIVOR BENEFITS, Please list the % of your annuity to be used as a base for the survivor annuity if other than 100%. *Your spouse
must sign below.
%
SPOUSE’S SIGNATURE

NAME OF SURVIVOR (If Married, list Spouse)
RELATIONSHIP

WITNESS TO SPOUSE’S SIGNATURE
(Other than spouse)

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As the spouse of ______________________________________________(name of employee), I fully understand that
he/she has not elected the maximum survivor benefits under the provisions of the Exchange Retirement Plan(s) which
would provide the maximum annuity to continue to me in the event my spouse should predecease me.

U.S. CITIZEN?

YES

ADDRESS (Number and Street, City, ST ZIP Code)

NO

DATE of BIRTH

SSN:

SIGNATURE of SURVIVOR

SECTION B – WORKERS’ COMPENSATION HISTORY (To be completed by employee)
HAVE YOU FILED AN EXCHANGE WORKERS’ COMPENSATION CLAIM?
If so, is the claim open?

YES
NO
YES
NO
I understand that I have received, or later receive, Exchange Workers’ Compensation payments, my retirement annuity may be offset to recover any overpayment,
or reduced in accordance with maximum benefits payable under the Exchange Retirement Plan.
EMPLOYEE’S SIGNATURE
WITNESS TO SIGNATURE

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SECTION C – MILITARY SERVICE (Completed by employee)
Have you performed active duty in the Armed Forces of the United States that terminated?
YES
NO
**If “Yes”, please complete the questions below. Attach a copy of Discharge/Separation Certificate. Were you honorably discharged?
YES
NO
BRANCH OF SERVICE
SERIAL NUMBER
ENTRANCE ON ACTIVE DUTY
SEPARATION FROM ACTIVE DUTY
Are you in receipt of, have you ever applied for, or are you entitled to draw military retirement pay?
(Retirement pay does not include VA pension or compensation) If “YES”, is such retirement pay:

YES

NO

A.

Due to a service connected disability incurred in combat with an enemy of the United States?

YES

NO

B.

Due to a service connected disability caused by an instrument of war and incurred in the line of duty during a period of war?

YES

NO

C.

Under the provisions of Chapter 67, Title 10, United States Code pertaining to retirement from reserve component of the Armed Forces?

YES

NO

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If A, B, or C above is “YES”, please submit a copy of your retirement orders along with this form.
SECTION D – CERTIFICATION OF MEMBER (To be completed by employee)

I understand that the retirement benefit elected above will begin the 1st of the month following my last day worked in accordance with the Retirement Plan under which I am covered. I certify that
the information on this form and dates of birth submitted are true and correct to the best of my knowledge. I also agree to assign to the proper payment provider a portion of my annuity, if required,
to satisfy any overpayment made by the provider. I have read the Definitions and Facts of Annuities pertinent to designation of type of annuity.
EMPLOYEE’S SIGNATURE

WITNESS SIGNATURE

DATE

SECTION E – RELEASE CLAUSE (ONLY If employed with the Exchange prior to 1967)
In consideration of the Army and Air Force Exchange Service securing from Bankers Trust its agreements to periodically pay the benefits to which I am entitled under Group
Annuity Contract 185 GAC, and/or Aetna 3056 the continuation of such payments being guaranteed by the Exchange, I hereby on behalf of myself, my beneficiary, heirs,
executors, administrators and assigns release and forever discharge the John Hancock and/or Aetna Retirement Services from any and all right, title and interest which I ever
had, now have, or at any time in the future may have in or to annuities and benefits at any time provided under Group Annuity Contract 185 GAC, issued by the John Hancock
Mutual Life Insurance Company and/or Aetna contract 3056 to the Army and Air Force Exchange Service (AAFES), by reasons of my contributions and those of the Exchange
made thereunder.
EMPLOYEE’S SIGNATURE

WITNESS SIGNATURE

DATE

SURVIVOR ANNUITANT SIGNATURE (if any)

WITNESS TO SIGNATURE OF SUVIVOR ANNUITANT

DATE (if other than above)

SPOUSE’S SIGNATURE

WITNESS TO SPOUSE’S SIGNATURE

DATE (if other than above)

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