RI 20-120 Request for Change to Unreduced Annuity_Revised

OMB Approval 3206-0245

Claim number

CSA
U.S. Office of Personnel Management
Retirement Operations Center
Post Retirement
Attention: Y-Adjustment
P.O. Box 45
Boyers, PA 16017-0045

Request for Change to Unreduced Annuity
In order to change my benefit to the unreduced annuity rate, I am providing the
information below.
The reason my marriage ended is:

Spouse Died

Divorce

Annulment

The date my marriage ended is: ______________________________________________
I have enclosed: (Check one block below.)
A copy of the death certificate.
A court-certified copy of my divorce decree, including all property settlements.
A court-certified copy of my annulment.
I understand that if I have self and family health benefits coverage, I can change to selfonly at any time.
Change my coverage to self-only.
(Note: Check this block if you want to make the change. A former spouse is no longer a
family member and is not eligible for coverage under your family enrollment.)
Signature (do not print)

Date (dd/mm/yyyy)

Name (last, first, middle initial)

Email address

Telephone no. (include area code)

RI 20-120
Revised September 2021