RI25-014_MarkUp

Form Approved: OMB No. 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:

A
F

Show any change of address
on this form below:

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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.
4. Student's Social Security Number

3. Is the student's date of birth correct as shown in item 1 above?
No. Show the correct date below and
attach a birth certificate.
Day
Year

Yes
Month

5. Is the student currently married?
No

Social Security Number

Month

Yes. Show the
marriage date below.
Year

JAN

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JAN

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FEB

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MAR

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APR

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APR

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MAY

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MAY

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JUN

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JUL

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JUL

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AUG

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AUG

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SEP

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SEP

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OCT

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OCT

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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

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):

Year

JAN

0

0

FEB

1

1

MAR

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APR

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MAY

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JUN

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JUL

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AUG

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SEP

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OCT

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8. Is this school accredited by a nationally
recognized accrediting agency or
association?
No

Yes

Phone number (if available & area code):

NOV
DEC
Previous editions are not usable

(

)
RI 25-14
Revised June 2011

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

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0

FEB

1

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FEB

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MAR

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MAR

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APR

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APR

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MAY

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MAY

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JUN

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JUN

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JUL

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JUL

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AUG

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AUG

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SEP

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SEP

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OCT

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OCT

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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

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

Year

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

B: Credit Hours such
as for college.

JAN

0

0

Jr. College/College/
Community College/or University

FEB

1

1

Other: Indicate type of school

MAR

2

2

APR

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MAY

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JUN

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JUL

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AUG

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SEP

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OCT

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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

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).

Signature of payee (person who is receiving the payments) Email address

Daytime telephone number (including area code)

(
Signature of student

Total Hours

Total Hours

Email address

)

Date (month/day/year)

Added Privacy Act and Public Burden Statements

Reverse of RI 25-14
Revised June 2011