Form Standard Form 3119 Standard Form 3119 Application for Court-Ordered Benefits for Former Spouse

OMB Approval 3206-XXXX

Application for Court-Ordered Benefits for Former Spouse
Use this application if you are the former spouse of a Federal employee/annuitant covered by the Civil Service Retirement System
(CSRS) or the Federal Employees Retirement System (FERS), you wish to apply for a court-ordered retirement benefit, and you have
obtained a court-order acceptable for processing.
You can also find this form on our website at www.opm.gov/retirement-services/my-annuity-and-benefits/life-events?#url=CourtOrder.
Supporting documentation must be submitted with this application. This includes an original or certified copy of the court order with
the judge's signature that meets all requirements for state certification of court orders. Additionally, all documents referenced in the
court orders must be included as well as marriage certificates, divorce decrees, and/or death certificates for additional marriages
(see Section C). Divorce decrees include, but are not limited to, the Property/Marital Settlement Agreement, Divorce Decree, or
Qualified Domestic Relations Order, etc. If you have already submitted a certified copy of the court order, you do not need to
submit it again.
Please return the completed form as well as any supporting documentation to: OPM, Court Ordered Benefits, P.O. Box 17,
Washington, D.C. 20044.
Court ordered payments of Thrift Savings Plan benefits or military retirement are not administered by OPM.
If your address changes after your application has been forwarded to the Office of Personnel Management, call us at 1-888-767-6738.
Hearing impaired applicants should use the Federal Relay Service by dialing 711 or their local communications provider to reach a
Communications Assistant. If you prefer, you can write to us at the address above. If you have received your claim number, please
refer to it. If you have not received your claim number, we will need your name, date of birth, and social security number. We will
also need the name, date of birth, social security number and claim number for the Federal employee/annuitant, if you have it.

Instructions for Completing Application
Type or print clearly. If you need more space in any section,
use a plain piece of paper with your name, date of birth, and
Social Security Number written at the top. If you do not know
an answer, write "unknown." If you are unsure of information
(for example, if you do not know an exact date), answer to the
best of your ability, followed by a question mark (?).

Item 3:

Enter the address of the Federal employee
or annuitant.

Item 4:

Enter a telephone number of the Federal employee/
annuitant. If not known, please write or type
“unknown.”

The following instructions can help you, the former spouse or
the person applying on behalf of a former spouse, answer the
questions on the application which may not be entirely selfexplanatory.

Section B - Former Spouse Information
Item 1:
Enter your name as it appears on the court order.
Item 2:

Enter your current name.

Section A - Federal Employee/Annuitant Identifying
Information
Item 1:
Enter the name of the Federal employee or annuitant.

Item 3:

Enter your date of birth.

Item 4:

Enter your Social Security Number.

Item 2:

Item 5:

Enter your current mailing address.

Item 6:

Enter your telephone number.

Item 7:

Enter your e-mail address to receive information
about your benefits from OPM via e-mail.

Item 8:

If yes, enter the name of your attorney or other legal
representative.

Enter other names under which the Federal
employee or annuitant has been employed in the
Federal government (such as a maiden name).
This will help us to locate and identify records
maintained under these names.

CSRS/FERS Handbook for Personnel and Payroll Offices
3119-101

Standard Form 3119
(Instruction page 1 of 2) November 2020

Section C - Marital Information
Item 1:
Provide the dates of your marriage and divorce from
the Federal employee/annuitant.
Item 2:

Indicate whether you remarried before age 55,
or, indicate whether the former spouse remarried.
If you answer "yes," please enter the date of
marriage.

Item 3:

Indicate whether you are currently married, or,
indicate whether the former spouse is currently
married. If you answer "yes," please enter the date
of marriage.

Item 4:

List dates of all marriages.

Section D - Payment Instructions
Complete in all cases. The US Department of the Treasury pays
all Federal benefit payments electronically. Most Federal
benefit payments are paid by Direct Deposit into a savings or
checking account at a financial institution. If you do not have
an account at a financial institution, or prefer not to have your
former spouse benefit payments deposited directly to your
account, you can choose a Direct Express debit card.

If you choose this option, your annuity payment will be
automatically deposited to the Direct Express debit card on the
payment date. To obtain a debit card, go to www.godirect.gov
or call 1-800-333-1795. If your payments are not directly
deposited to your account and you do not have a Direct Express
card, you must contact the Department of the Treasury at
1-800-333-1795.
Once former spouse payments have begun, you (or the
former spouse if applying on behalf of someone else)
will be sent a password for Services Online
(https://www.servicesonline.opm.gov/).
Section E - Applicant's Certifications
Provide information regarding certification that the current
court order is in force and has not been amended, superseded,
or set aside and whether there are current payments from the
annuitant/employee. Be sure to sign (do not print) and date
your application after reviewing the warning.
Former Spouse Checklist
This section is intended to help make certain you have provided
all of the necessary information and documentation we need to
process your application for former spouse benefits.

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 Title 5, U.S. Code, Chapter 84. 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: OPM is requesting this information to identify records properly associated with your application for Federal
benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a uniquely identifiable
claim file. 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 application for benefits. 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 determination
or continuation of benefits under this program, 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, if you fail to provide this
information, it may result in a delay or prevent action on your application.
Public Burden Statement
We estimate this form takes an average of 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 United States Office of Personnel Management (OPM), Retirement Services Publications Team (3206-XXXX), Washington,
D.C. 20415-0001. Completed application forms should not be sent to this address. The OMB Number 3206-XXXX, is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is displayed.

Standard Form 3119
(Instruction page 2 of 2) November 2020

OMB Approval 3206-XXXX

Application for Court-Ordered Benefits for Former Spouse
Section A - Federal Employee/Annuitant Identifying Information
1.

Full name (last, first, middle)

2.

3.

Address (number, street, city, state and ZIP code)

5. Date of birth (mm/dd/yyyy)

6.

List all other names used

Social Security Number

4a.

Daytime telephone number (including area code)

4b.

E-mail address

7.

CSA/CSF Claim Number

Section B - Former Spouse Information
1.

Full name (last, first, middle) as it appears on the court order

3. Date of birth (mm/dd/yyyy)
5.

4.

2.

Current name

Social Security Number

Address (number, street, city, state and ZIP code)

6a. Telephone number (including area code)

6b. Best time to reach you

7.

E-mail address

8.

Do you have current legal representation?

No

►

Yes (If yes, provide name and contact information)

Section C - Marital Information
1.

When were you married to the Federal employee/annuitant?

2.

Did you remarry before the age of 55?

No

Yes (If yes, provide the date of marriage
and divorce, if applicable)

Date of Marriage (mm/dd/yyyy)

Date of Divorce (mm/dd/yyyy)

Date of Marriage
(mm/dd/yyyy)

Date Marriage Ended
(mm/dd/yyyy)

►

►

3.

Are you married now? (A marriage exists until ended by death, divorce or annulment.)

4.

List dates of all marriages (you must provide copies of marriage certificates, divorce decrees, and/or death certificates for all marriages listed)

No
Date of Marriage
(mm/dd/yyyy)

Yes (If yes, provide date of marriage [mm/dd/yyyy])
Date Marriage Ended
(mm/dd/yyyy)

►

Date of Marriage
(mm/dd/yyyy)

Date Marriage Ended
(mm/dd/yyyy)

Standard Form 3119
November 2020

Section D - Payment Instructions for Former Spouse Benefit
1.

Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department of
the Treasury. See the instructions for Section D of this application for additional information. This does not apply to you if your permanent payment address is outside the
United States in a country not accessible via Direct Deposit.
Please select one of the following:

Please send my annuity payments directly to my checking or savings account (Go to item 2a)
Please send my annuity payments to my Direct Express debit card.
My permanent payment address is outside the United States. (Go to item 2a)
2a. Financial Institution Routing Number

You may obtain this number by calling your bank, credit union, or savings institution.
This number is very important. We cannot pay by direct deposit without it.

2b. Checking or Savings Account Number 2c. What kind of account is this?

Checking

2d. Telephone number of your Financial Institution (including area code)

Savings

2e. Name and address of Financial Institution

Special Note: If you prefer, you may attach a cancelled personal check
that shows the information requested above, instead of filling in the
requested financial institution information. If you attach your personal
check, it is especially important that you contact your bank, credit union,
or savings institution to confirm that the information on the check is the
correct information for direct deposit. (Some institutions, especially
credit unions, use different routing numbers on checks.) We can then
use this information to start paying you by direct deposit.

Section E - Applicant's Certification
1.

Do you certify that the court order submitted with this application is currently in force and has not been superseded or set aside?

2.

Have you (as the former spouse) been receiving monthly payments from the annuitant?

No
No

Yes
Yes

Warning
I hereby certify that all statements made in this application are true to the best of my knowledge and belief.
Any intentionally false statement in this
Signature (do not print)
Date (mm/dd/yyyy)
application or willful misrepresentation
relative thereto 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 U.S.C. 1001)

Applicant's Checklist
This checklist is provided to help ensure that you attach and submit all the necessary documentation to the Office of
Personnel Management.

Yes

No

Not
Applicable

1. Court Orders - Did you submit all court orders completed incident to your divorce? This will include the
Property/Marital Settlement Agreement, Divorce Decree, or Qualified Domestic Relations Order, etc.
Additionally, all documents referenced in the court orders must be included. If you have already submitted
a certified copy of the court order, you do not need to submit it again.
a. All court orders must be court certified with the judge's signature and meet all requirements for state
certification of court orders. These requirements may include a raised seal (impressed on paper), gold seal,
or an ink signature.
b. We must have an original or certified copy of all court orders before payment can be made.
2. Personal Information - Did you provide sufficient information to identify the employee/annuitant (full name,
retirement claim number, date of birth, address, and social security number)?
3. Former Spouse Information - Did you provide sufficient information to identify yourself (full name,
retirement claim number, date of birth, address, and social security number)?
4. Completion of Application - Have you reviewed your application to make sure you answered all questions
completely to the best of your knowledge?
5. Statement of Remarriage - Do you have a statement of remarriage? If the benefit awarded in the court order is
subject to termination upon remarriage, a signed statement from the applicant stating that remarriage has not
occurred is required. If you remarry after the date of this application, you must promptly inform OPM about the
remarriage. You will be held liable for any overpayment as a result of this marriage.
6. Submit all additional documents (marriage certificates, divorce decrees, death certificates).

Reverse of Standard Form 3119
November 2020