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pdfOMB Approval 3206-0032
U.S. Office of Personnel Management
Retirement Surveys & Students Branch, Washington, DC 20415-3563
Self-Certification of Full-Time School
Attendance For The School Year:
Show any change of address
on this form below:
A
0
0
0
0
0
0
0
0
0
F
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
6
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7
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7
7
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7
7
8
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
9
For Agency Use Only
1. Student's name and date of birth
I
II
III
IV
Claim number
2. Currently certified thru
Date
IMPORTANT: Please read the enclosed instruction sheet before completing this form. To avoid interruption of payments, please complete this form
immediately, using a pencil and darkening the entire oval; so our computer can process your form without delaying your payments. Please complete this
form for the entire school year (not just one semester) if plans are known; and complete it for one school year only. Please do not take this form to the
school. The person in the address above must sign in item 17. This is a personalized form, precoded for only the student shown in item 1.
No. Show the correct date below and
attach a birth certificate.
Day
Year
Yes
Month
5. Is the student currently married?
4. Student's Social Security Number
3. Is the student's date of birth correct as shown in item 1 above?
No
Month
Social Security Number
Yes. Show the
marriage date below.
Year
JAN
0
0
0
0
0
0
0
0
0
0
0
0
0
JAN
0
0
FEB
1
1
1
1
1
1
1
1
1
1
1
1
1
FEB
1
1
MAR
2
2
2
2
2
2
2
2
2
2
2
2
2
MAR
2
2
APR
3
3
3
3
3
3
3
3
3
3
3
3
3
APR
3
3
MAY
4
4
4
4
4
4
4
4
4
4
4
4
MAY
4
4
JUN
5
5
5
5
5
5
5
5
5
5
5
5
JUN
5
5
JUL
6
6
6
6
6
6
6
6
6
6
6
6
JUL
6
6
AUG
7
7
7
7
7
7
7
7
7
7
7
7
AUG
7
7
SEP
8
8
8
8
8
8
8
8
8
8
8
8
SEP
8
8
OCT
9
9
9
9
9
9
9
9
9
9
9
9
OCT
9
9
NOV
NOV
DEC
DEC
6. During the past 12 months, did the student stop school before the end
of the school term, or change from full-time to part-time status?
Yes. Show date full-time attendance ended.
Month
Year
JAN
0
0
FEB
1
1
MAR
2
2
APR
3
3
MAY
4
4
JUN
5
5
JUL
6
6
AUG
7
7
SEP
8
8
OCT
9
9
NOV
DEC
Previous editions are not usable
No
Items 7 - 16 must be completed if the student
returned or will return to school full-time on
or after the date shown in item 2 above.
7. Show the school's name and address
(including ZIP code):
8. Is this school accredited by a nationally
recognized accrediting agency or
association?
No
Yes
Phone number (if available & area code):
(
)
RI 25-14
Revised July 2020
9. Enter the date the student began or will begin
full-time school attendance for the school year
you are certifying. Date should be on or after date
shown in item 2.
Month
Day
Year
10. Enter the date this school attendance will
end or ended. If the student plans to attend
for the full school year, you should show the
ending date of the full school year (NOT the
semester). This date must be later than the
date shown in item 9.
Month
Day
Year
JAN
0
0
0
0
JAN
0
0
0
0
FEB
1
1
1
1
FEB
1
1
1
1
MAR
2
2
2
2
MAR
2
2
2
2
APR
3
3
3
3
APR
3
3
3
3
MAY
4
4
4
MAY
4
4
4
JUN
5
5
5
JUN
5
5
5
JUL
6
6
6
JUL
6
6
6
AUG
7
7
7
AUG
7
7
7
SEP
8
8
8
SEP
8
8
8
OCT
9
9
9
OCT
9
9
9
NOV
11. Is the date given in item 10 the end of
the school year?
Yes
No
12. Does the student intend to return to school full-time
after the date shown in item 10, with less than a 5
month break?
Undecided
No
Yes. Show the beginning date of
the next school year in item 13.
NOV
DEC
DEC
13. Enter the estimated date the student will
begin full-time attendance for the NEXT
school year after the school year shown
in items 9-10.
Month
Year
14. Type of School shown in item 7.
15. Attendance for School shown in item 7.
Mark only one (A or B) below
High School
A: Classroom Hours
per week, such as for
High Schools or trade
schools. (Combine
work/study hours if
in a high school work
study program.)
Trade/Technical/or Vocational
Jr. College/College/
Community College/or University
B: Credit Hours such
as for college.
JAN
0
0
FEB
1
1
MAR
2
2
APR
3
3
0
0
0
0
MAY
4
4
1
1
1
1
JUN
5
5
2
2
2
2
JUL
6
6
3
3
3
3
AUG
7
7
4
4
4
4
SEP
8
8
5
5
5
OCT
9
9
6
6
6
7
7
7
8
8
8
9
9
9
Other: Indicate type of school
NOV
DEC
16. Is the student in a school-sponsored co-op
or internship program?
Yes (Attach a letter from the school
explaining the program.)
No
Total Hours
Total Hours
WARNING: Any intentionally false statements or willful misrepresentations are punishable by fine,
imprisonment, or both (18 USC 1001).
17. I certify that all information given in this certification is true and correct to the best of my knowledge and belief. I understand that
I must immediately notify the Office of Personnel Management (OPM) if the student transfers to another school, discontinues school
attendance, reduces attendance to less than full-time, marries or dies. I agree to return all overpayments of student benefits, including
overpayments that may be made after I notify OPM of any terminating event. I authorize the appropriate school official to verify my
school attendance status to OPM in the manner requested by OPM (e.g., by telephone, fax, email, or written correspondence).
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, USC, Chapter 83, Section 8341 and Chapter 84, Section 8441, which, provides for survivor benefits for children of deceased Federal employees, including adult students age 18 to 22 who are unmarried and are full-time
students in recognized schools. 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 determine whether to continue the student benefits. 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 is voluntary. However, failure to provide this information may result in the noncompliance of the provisions of Title 5, USC, Sections 8341 and Chapter 84, Section 8441.
Individuals who do not provide this information can also request changes via telephone or letter, as well as using RI 25-14. The information collected can only be obtained from the respondents.
Public Burden Statement
We estimate this form takes an average of 12 minutes per response to complete, including the time for reviewing instructions, getting the needed data, and reviewing the requested information. 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 (3206-0032), Washington, D.C. 20415-0001.
The OMB number, 3206-0032, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Signature of payee (person who is receiving the payments) Email address
Signature of student
Email address
Daytime telephone number (including area code)
(
)
Date (month/day/year)
Reverse of RI 25-14
Revised July 2020
| File Type | application/pdf |
| File Title | Printing C:\PHYLLIS\...\JUNE20~1\RI25-014.FRP |
| Author | phyllis |
| File Modified | 2020-01-27 |
| File Created | 2011-03-24 |