RI 34-1 Financial Resources Questionnaire

Form approved:
OMB No. 3206-0167

Financial Resources Questionnaire
U.S. Office of Personnel Management
Retirement Services Program

General Information
The purpose of this questionnaire is to determine your eligibility for:
1. waiver of the amount due the retirement system on the basis of
financial hardship;
2. compromise in the amount to be repaid;
3. lower installments; and/or
4. a voluntary repayment agreement.
For more information on waiver, compromise, lower installments, or
voluntary repayment, please refer to our letter or notice informing you
of the overpayment. (Note: If you are only requesting lower installments,
you do not need to fill out this questionnaire as long as your payments will
be (1) at least $50 a month and (2) sufficient to pay off the entire amount
within three years.)
Failure to supply all the requested information may result in an
unfavorable decision. Please note that you may be asked to provide
verification of the information you supply in this questionnaire
(e.g., evidence of claimed expenses).
To be considered for waiver, compromise, lower installments, or a
voluntary repayment agreement, you must complete and return this
questionnaire to us within 30 days after the date shown in the notice
of overpayments.

General Instructions
1.
2.
3.

Please read all items carefully.
Type or print in ink.
Complete all items on the form. If a question does not apply, answer
“No” or “None”. Do not leave it blank. If answers require additional
space, continue them in Section X. Attach additional sheets if
necessary. Include your name and retirement claim number in the
upper right corner of each additional sheet.

4.
5.

Sign and date this questionnaire in Section XI.
Send the completed form to:
Office of Personnel Management
Attn: Legal Reconsideration Branch
1900 E. ST N.W., Room 3349
Washington, DC 20415

Detailed Instructions
Most of the questionnaire items are self-explanatory. Instructions are
provided below for those items identified with an asterisk (*), which
require further explanation.
Section I - Personal Data
Item 1 Give the name of the former Federal employee upon whose
service your entitlement to retirement system benefits was
based. (If the benefits are based upon your own service, give
your name.)
Section IV - Average Monthly Income
Item 1

Enter your current monthly gross salary - i.e., wages, fees,
commissions - for yourself and then your spouse. (Enter the
total salary paid before any payroll deductions are made; e.g.,
Federal, state, and local taxes; social security taxes; insurance,
etc.) If your salary fluctuates on a monthly basis, estimate the
monthly average.

Previous edition is not usable

Item 6

Enter all other current income not listed. This may include
unemployment compensation, public assistance benefits, trust
income, tax refunds, alimony, child support, royalties, payments
of debts owed to you, income provided by dependents listed in
Section I (other than spouse), etc. Estimate the average monthly
amount.

Section V - Average Monthly Expenses
Item 1 Enter the amount you currently spend on average for rent,
mortgage, homeowner/condominium fees, etc., each month.
If you include property taxes in this item, do not include them
in V.9.
Item 3
Item 4

Enter the average monthly amount you spend for electricity,
telephone, gas, water, coal, oil, etc.
Enter the average monthly amount you spend for household
maintenance (repairs, cleaning supplies, etc.) and personal
necessities.

Item 7

Enter the average monthly amount you spend for insurance
(life, health, accident, automobile, homeowners, etc.).
Do not include homeowner’s insurance if it is already
included in item V.1.

Item 8

Transportation costs include necessary automobile expenses
(gas, oil, maintenance), cab fares, and public transportation.
Enter 1/12 of all taxes you pay in a year, including Federal,
state, and local taxes; property taxes not included in item V.1;
sales taxes not included in other items, etc.

Item 9

Item 10 Enter the total amount due monthly from existing liabilities as
shown in Column E of Section VII. (This amount should not
include any expenses - such as mortgage payments - listed
under other items in Section V.)
Item 11 Other living expenses which you can prove to be ordinary and
necessary. Provide a breakdown of these expenses in Section X.
Section VIII - Assets
Item 4 Enter the cash value of your money market accounts,
certificates of deposit, etc. Do not include Individual
Retirement Accounts (IRA’s) or other interest bearing
accounts which belong in item 6.
Item 5

The current value on any stocks or bonds you own.
The current value is the amount you would receive if you
sold these securities.

Item 6

The current value of any IRA’s, Keoughs or similar retirement
savings accounts.
Identify any automobiles, vans, trucks, motorcycles, motor
homes (RV’s), trailers, campers, boats, etc., that you own,
and their resale value (the amount you would receive if you
sold these vehicles). Any remaining liabilities for these
vehicles should appear in Section VII.

Item 8

Item 9

The resale value of your home and other real estate. (If you
own two or more properties, list separately. Also show the
unpaid amount of any real estate mortgages in Section X.)

Item 10 The current resale value of any other personal property (art
pieces, jewelry, etc.) which can be sold and which are valued
in excess of $1,000 per item. (Itemize in Section X.)

RI 34-1
Revised July 2018

Financial Resources Questionnaire
For Consideration in Connection With Collection of an Overpayment
Please read the attached instructions and Privacy Act Statement before completing this form.

Section I - Personal Data
*1. Name of former Federal employee (Last, first, middle)

2. Claim number

3. Former Federal employee's date of birth
(mm/dd/yyyy)

4. Your name

5. Your date of birth (mm/dd/yyyy)

6. Your social security number

7. Your address

8. Your telephone number (including area code)

9. Your dependents (list spouse first):
Name (Last, first, middle)

Relationship

Date of Birth

Social Security Number

Section II - Your Current/Most Recent Employment

Section III - Spouse's Current/Most Recent Employment

1. Current or most recent position
(e.g., Salesclerk)

1. Current or most recent position
(e.g., Salesclerk)

2. Dates of employment
From (mm/yyyy)
To (mm/yyyy)

2. Dates of employment
From (mm/yyyy)
To (mm/yyyy)

3. Name and address of employer

3. Name and address of employer

Section IV - Average Monthly Income

Section V - Average Monthly Expenses

Type of Income
*1. Gross salary or wages (before payroll
deductions)

Your Income

$

Spouse's Income

$

Type of Expense
*1. Rent/mortgage payments, homeowner/
condominium fees
2. Food

2. Self-employment (net)

3. Gross retirement benefits:
Military retired or retainer pay
Social Security
Payments from OPM
Other (specify)

Monthly Average

$
$

*3. Utilities

$

*4. Household maintenance

$

5. Clothing

$

6. Medical and dental
(non-reimbursable)

$

*7. Insurance premiums

$

4. Disability benefits
(Veterans benefits,
Workers' Compensation, etc.)

*8. Transportation

$

*9. Taxes (1/12 of all yearly taxes)

$

5. Investments
(interest, dividends,
rental income, etc.)

*10. Monthly payments on existing installment
contracts and other debts
(Total from Section VII)

$

*6. Other (itemize in Section X)

*11. Other ordinary and necessary living expenses

7. Total average monthly income (add
items 1 thru 6)

$
$

$

12. Total average monthly expenses
(add items 1 thru 11)

$

*See "Detailed Instructions" for an explanation of this item.
Previous edition is not usable

RI 34-1
Revised July 2018

Section VI - Summary
1. Total Monthly Income (Section IV, line 7, combined)

$

2. Total Monthly Expenses (Section V, line 12)

−

3. Balance (Subtract line 2 from line 1 above)

$

4. How much of the balance in item 3 can you apply
$
toward repayment on a monthly basis?
5. If your monthly expenses exceed your monthly income, how do you pay the
difference?

Section VII - Installment Contracts and Other Debts
Show here all debts which you are required to pay in regular monthly installments, such as car, television or appliance payments to dealers, banks, or financial companies;
repayment of money borrowed for any purpose; charge accounts and credit card payments; doctor or hospital bills; taxes owed; etc. Do not include expenses (such as mortgage
payments) already listed in Section V, exclusive of item 10. Note: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay in
Section X.
(A) Name and Address of Creditor

(B) Purpose of Debt

Total

(C) Original Amount (D) Unpaid Balance
of Debt

(E) Amount Due
Monthly

$

$

$

$

$

$

(F) Scheduled Date of
Full Repayment

Section VIII - Assets
Type of Asset
1. Cash on hand

Value

$

Type of Asset
*6. Individual Retirement Accounts

Value

$

2. Checking account(s). Give name and address of financial institution(s) below

$

$
7. Debts owed to you (give name of debtor)

$

$
3. Savings account(s). Give name and address of financial institution(s) below

$
*8. Vehicles
Type of Vehicle

Make

Model

Year

Resale Value

$

$

$

$
$

*4. Other interest-bearing account(s)

$

*9. Resident real property & other real property owned (itemize below or in Section X)

$

$
$

*5. Stocks, bonds, and other securities (itemize below or in Section X)

$

$

$

*10. Other assets (itemize in Section X)

$

$

11. Total assets (total of lines 1 thru 10)

$

*See "Detailed Instructions" for an explanation of this item.

Section IX - Additional Data
If "Yes", give details in Section X.

Yes

No

1. Is anyone holding money or assets on your behalf?
2. Is there any likelihood that you will receive an inheritance or benefits from a trust?
3. Do you have any of the incorrectly paid checks in your possession?
(If "Yes", show the total amount and return the checks immediately.)

$___________________________________________

Section X - Remarks
Use this space and additional sheets if necessary to supply any other pertinent information and to continue your answers to previous items. Indicate section
and item number to which your comments apply.

Section IX - Certification
I affirm that the information provided herein is true, correct, and complete to the best of my
knowledge and belief.
1. Your signature

2. Date (mm/dd/yyyy)

Warning
Any intentionally false statement, concealment of material fact or
willful misrepresentation relative to this questionnaire is punishable
by a fine of not more than $10,000 or imprisonment for not more
than 5 years, or both (18 U.S.C. 1001). You may be asked to furnish
verification of any statement you make.

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 requested on this form pursuant to 5 U.S. Code § 8337 (Civil Service Retirement) and 5 U.S.C. chapter 84, subchapter V (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: This form is used to collect detailed financial information for use by OPM to determine whether to agree to a waiver, compromise, or adjustment of the collection of
erroneous payments from the Civil Service Retirement and Disability Fund. Routine Uses: The information requested on this form may be shared as a "routine use" to other
Federal agencies and third-parties when it is necessary to process your application. For example, OPM may share your information with other Federal, state, or local agencies
and organizations in order to determine benefits under their programs, to obtain information necessary for a determination of your disability retirement benefits, 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 the 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 this information to OPM is voluntary. However, failure to provide this information may result in an
unfavorable decision or financial investigation of the person who owes the United States.

Public Burden Statement
We estimate this form takes an average 60 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
(OPM), Retirement Services Publications Team (3206-0167), Washington, D.C. 20415-0001. The OMB number, 3206-0167, is currently valid. OPM may not collect this
information, and you are not required to respond, unless this number is displayed.