RI 20-63 Survivor Annuity Election for a Spouse

OMBApproval 3206-0174

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

Your claim number

CSA

I

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

Spouse's date of birth

Spouse's Social Security Number

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)

E]

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 the information requested on this form pursuant to Title 5, U.S.C, Chapter 83, 83390)(5)(C)(i) and (k)(2) and Sections 8416(b) and (c) which states annuitants may
elect to provide survivor annuity benefits for a spouse whom they marry after retirement. 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 to file a specific written election
to provide a survivor annuity. 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 delay or prevention of annuitants electing
survivor benefits. Individuals who do not provide this information can also request changes via telephone or letter, as well as using RI 20-63. The information collected can
only be obtained from the respondents.

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 Office of Personnel
Management, Retirement Services Publications Team (3206-0174), Washington, DC 20415-0001 . The 0MB 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 editions are not usable.

RI 20-63
Revised February 2021