RI 20-64A Former Spouse Survivor Annuity Election_Revised

Office of Personnel Management
Civil Service Retirement System
Boyers, PA 16017

OMB Approval 3206-0235

Former Spouse Survivor Annuity Election
Civil Service Claim Number
CSA

Part 1: To Be Completed by Retiree
1. Your name (last, first, middle)

2. Are you now married? (If yes, complete item 2a
and see note below.)
No
Yes

2a. Name of current spouse (last, first, middle)

3. Former spouse's name (last, first, middle)

4. Former spouse's Social Security Number

5. Former spouse's mailing address

6. Election: I elect a reduced annuity to provide a survivor annuity for my former spouse named in block 3 above. I have read and
understand the information in the accompanying letter and pamphlet.
(Choose one of the following as a base for computing the former spouse survivor annuity.)
Use the maximum amount now available.

Use the same amount for which my annuity is now reduced.

Use the amount that will currently provide a survivor annuity rate of $__________ per month. (Specify a whole dollar amount, not
more than the survivor rate shown in item 4 of Part B in the letter.)
Important: This Election Is Irrevocable After You Submit It To OPM.
7. Your signature (do not print)

8. Date (mm/dd/yyyy)

9. Daytime telephone number (including area code)

Note: Married retirees must have their current spouse's written consent to this election. If you are married, have your current spouse
complete Part 2. Part 2 must be completed in the presence of a Notary Public or other person authorized to administer oaths. The certifier
must complete Part 3. The current spouse consent requirement may be waived under certain conditions. See Part II of the enclosed
pamphlet for more information. If you want to request a waiver, attach an explanation to this application.
Part 2: To Be Completed by Current Spouse if Retiree Is Married
I freely consent to the survivor annuity election described above. I understand that my consent is final and cannot be revoked.
1. Name (type or print)

2. Signature (do not print)

Part 3: To Be Completed by A Notary Public Or Other Person Authorized to Administer Oaths
I certify that the person named in Part 2 presented identification (or was known to me), signed or marked this form, and acknowledged that
the consent was freely given in my presence on the ____________ day of ____________________________________________________
(month)
_______________ at ______________________________________________________________________________________________
(year)
1. Signature (do not print)

2. Name and title of certifier (type or print)

Seal
3. Expiration date of commission if Notary Public

Continues on the Reverse
Previous editions are not usable.

RI 20-64A
Revised August 2020

Part 4: If You Decide Not To Provide A Survivor Benefit
Please indicate your decision below, provide your signature and date, and return this election form to the address shown in Part C of the letter.
I have decided not to provide a survivor benefit for (enter name of person):
Signature

Date (mm/dd/yyyy)

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, Section 8339(j)(3) and Section 8417, which states that
annuitants may elect, after retirement, to provide survivor annuity benefits for a former spouse. 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 select the survivor benefit, obtain any current spouse’s consent to the election, or decline to make the election. 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 Title 5, U. S. Code, Section 8339(j)(3) and Section 8417. Individuals who do not provide this information can also request changes via
telephone or letter, as well as using RI 20-64A. The information collected can only be obtained from the respondents.

Public Burden Statement
We estimate the election letter takes an average 45 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 U.S. Office of Personnel Management, Retirement Services Publications Team (3206-0235), Washington, DC 20415-0001 The OMB Number,
3206-0235, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

RI 20-64A
Revised August 2020