RI 20-63 Survivor Annuity Election for a Spouse

Form Approved:
OMB Number: 3206-0174

Survivor Annuity Election for a Spouse
Your full name (Please print)

Your claim number
CSA:

Please Provide the Following information About Your Spouse
Spouse's full name (Please print)

Spouse's Social Security Number

Spouse's date of birth

Date of marriage (Your election must be received within two years after this
date)

Election: I elect a reduced annuity to provide a survivor annuity for my spouse named above. I have read and understand the information in
the accompanying letter. I understand that this election terminates if my marriage ends in divorce, annulment, or the death of my spouse.
Pamphlets are available on https//www.servicesonline.opm.gov.
(Choose one of the following as a base for computing the survivor annuity)
I elect the maximum survivor annuity benefit.
I elect a survivor annuity benefit equal to $____________________ per month. (Specify a whole dollar amount.
If my marriage terminates and I want to provide a survivor benefit for a former spouse, I understand that I must file a specific written election
with OPM within 2 years after the date of termination of my marriage.

Important: You Cannot Revoke This Election.
Your signature (Do not print)

Date

Email address

Daytime telephone number
(

)

To elect no survivor benefit for your spouse, write your initials in the block provided and sign your name below the block

I have read the enclosed information and have decided not to provide a survivor benefit. I have signed below.
Your signature electing no survivor benefits (Do not print)
Date

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 this information requested on this form by 5 U.S.C. § 8341 (Civil Service Retirement) and 5 U.S.C., chapter 84, subchapter IV (Federal
Employees' Retirement). OPM is authorized to collect your spouse's 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 in order to determine your eligibility to receive a reduced annuity
and to give a survivor annuity to your spouse. OPM will use this information primarily to determine your eligibility to receive a reduced annuity and to give a
survivor annuity to your spouse. 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 election. For example, OPM may share your information with other Federal, state, or local agencies and
organizations in order to determine your 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 delay or prevent OPM from being able to reduce your annuity and provide a survivor annuity to
your spouse.
Public Burden Statement
We estimate the election 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 (3206-0174), Washington, DC 20415-0001. The OMB Number,
3206-0174, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Previous edition is usable.

RI 20-63
Revised February 2018