RI 34-17 Financial Resources Questionnaire - Federal Employees’ G

OMB Approval 3206-0167

Financial Resources Questionnaire
Federal Employee's Group Life Insurance Premiums Underpaid
Office of Personnel Management
Retirement Operations

General Information

Item 6

The purpose of this questionnaire is to determine your eligibility for:
1. waiver of the amount due the retirement system on the basis of
financial hardship;
2. compromise in the amount to be paid;

Enter all other current income not listed. This may include
unemployment compensation, public assistance benefits, trust
income, tax refunds, alimony, child support, royalties, payments
of debts owed to you, income provided by dependents listed in
Section I (other than spouse), etc. Estimate the average monthly
amount.

3.

lower installments; and/or

Section V - Average Monthly Expenses

4.

a voluntary payment agreement.

Item 1

Enter the amount you currently spend on average for rent,
mortgage, homeowner/condominium fees, etc., each month. If
you include property taxes in this item, do not include them in
V.9.

Item 3

Enter the average monthly amount you spend for electricity,
telephone, gas, water, coal, oil, etc.
Enter the average monthly amount you spend for household
maintenance (repairs, cleaning supplies, etc.) and personal
necessities.
Enter the average monthly amount you spend for insurance
(life, health, accident, automobile, homeowners, etc.). Do not
include homeowner’s insurance if it is already included in item
V.1.
Transportation costs include necessary automobile expenses
(gas, oil, maintenance), cab fares, and public transportation.

For more information on waiver, compromise, lower installments, or
voluntary payment, please refer to our letter or notice informing you of
the underpayment of Federal Employee's Group Life Insurance premiums.
(Note: If you are only requesting lower installments, you do not need to fill
out this questionnaire as long as your payments will be (1) at least $50 a
month and (2) sufficient to pay off the entire amount within three years.)
Failure to supply all the requested information may result in an unfavorable
decision. Please note that you may be asked to provide verification of the
information you supply in this questionnaire (e.g., evidence of claimed
expenses).
To be considered for waiver, compromise, lower installments, or a
voluntary payment agreement, you must complete and return this
questionnaire to us within 30 days after the date shown in the notice of
underpayments.

General Instructions
1.

Please read all items carefully.

2.

Type or print in ink.

3.

Complete all items on the form. If a question does not apply, answer
“No” or “None”. Do not leave it blank. If answers require additional
space, continue them in Section X. Attach additional sheets if
necessary. Include your name and retirement claim number in the
upper right corner of each additional sheet.

4.

Sign and date this questionnaire in Section XI.

5.

Send the completed form to:
Office of Personnel Management
Attn: Legal Reconsideration Branch
1900 E ST N.W., RM 3349
Washington, DC 20415

Detailed Instructions
Most of the questionnaire items are self-explanatory. Instructions are
provided below for those items identified with an asterisk(*), which
require further explanation.
Section I - Personal Data
Item 1 Give the name of the former Federal employee upon whose
service your entitlement to retirement system benefits was
based. (If the benefits are based upon your own service, give
your name.)
Section IV - Average Monthly Income
Item 1 Enter your current monthly gross salary - i.e., wages, fees,
commissions - for yourself and then your spouse. (Enter the
total salary paid before any payroll deductions are made; e.g.,
Federal, state, and local taxes; social security taxes; insurance,
etc.). If your salary fluctuates on a monthly basis, estimate the
monthly average.

Previous editions are not usable.

Item 4

Item 7

Item 8
Item 9

Enter 1/12 of all taxes you pay in a year, including Federal,
state, and local taxes; property taxes not included in item V.1;
sales taxes not included in other items, etc.

Item 10 Enter the total amount due monthly from existing liabilities as
shown in Column E of Section VII. (This amount should not
include any expenses - such as mortgage payments - listed
under other items in Section V.)
Item 11 Other living expenses which you can prove to be ordinary and
necessary. Provide a breakdown of these expenses in Section X.
Section VIII - Assets
Item 4

Enter the cash value of your money market accounts, certificates
of deposit, etc. Do not include Individual Retirement Accounts
(IRA’s) or other interest bearing accounts which belong in item 6.

Item 5

The current value on any stocks or bonds you own. The current
value is the amount you would receive if you sold these securities.

Item 6

The current value of any IRA’s, Keoughs or similar retirement
savings accounts.

Item 8

Identify any automobiles, vans, trucks, motorcycles, motor
homes (RV’s), trailers, campers, boats, etc., that you own, and
their resale value (the amount you would receive if you sold
these vehicles). Any remaining liabilities for these vehicles
should appear in Section VII.

Item 9

The resale value of your home and other real estate. (If you
own two or more properties, list separately. Also show the
unpaid amount of any real estate mortgages in Section X.)

Item 10 The current resale value of any other personal property (art
pieces, jewelry, etc.) which can be sold and which are valued
in excess of $1,000 per item. (Itemize in Section X.)

RI 34-17
Revised August 2021

Financial Resources Questionnaire

For Consideration in Connection With Collection of an Underpayment of Federal Employee's Group Life Insurance Premiums
Please read the attached instructions and Privacy Act Statement before completing this form.

Section I - Personal Data
*1. Name of former Federal employee (last, first, middle)

2. Claim number

3. Former Federal employee's date of birth
(mm/dd/yyyy)

4. Your name

5. Your date of birth (mm/dd/yyyy)

6. Your social security number

8. Your telephone number (including area code)

7. Your address

9. Your email address
Your dependents (list spouse first):
Name (last, first, middle)

Relationship

Social Security Number

Date of Birth

Section II -Your Current/Most Recent Employment

Section III - Spouse's Current/Most Recent Employment

1. Current or most recent position
(e.g., Salesclerk)

1. Current or most recent position
(e.g., Salesclerk)

2. Dates of employment
To (mm/yyyy)
From (mm/yyyy)

3. Name and address of employer

3. Name and address of employer

Section IV - Average Monthly Income
Type of Income
*1. Gross salary or wages
(before payroll deductions)

2. Dates of employment
To (mm/yyyy)
From (mm/yyyy)

Section V - Average Monthly Expenses

Your Income

$

Spouse's Income

$

Type of Expense
*1. Rent/mortgage payments,
homeowner/condominium fees

Monthly Average

$

2. Food

2. Self-employment (net)

*3. Utilities
*4. Household maintenance
3. Gross retirement benefits:

5. Clothing

Military retired or retainer pay
Social Security
Payments from OPM
Other (specify)

6. Medical and dental
(non-reimbursable)
*7. Insurance premiums
*8. Transportation

4. Disability benefits
(Veterans benefits, Workers'
Compensation, etc.)

*9. Taxes (1/12 of all yearly taxes)

5. Investments
(interest, dividends, rental income, etc.)

*10. Monthly payments on existing installment
contracts and other debts
(Total from Section VII)

*6. Other (itemize in Section X)

*11. Other ordinary and necessary living expenses

7. Total average monthly income
(add items 1 thru 6)

$

$

12. Total average monthly expenses
(add items 1 thru 11)

$

*See "Detailed Instructions" for an explanation of this item.
RI 34-17
Revised August 2021

Section VI - Summary
1. Total Monthly Income
(Section IV, line 7, combined)

$

2. Total Monthly Expenses
(Section V, line 12)

-

3. Balance
(Subtract line 2 from line 1 above)

$

4. How much of the balance in item 3 can you apply toward
repayment on a monthly basis?

$

5. If your monthly expenses exceed your monthly income, how do you pay the difference?

Section VII - Installment Contracts and Other Debts
Show here all debts which you are required to pay in regular monthly installments, such as car, television or appliance payments to dealers, banks, or financial companies;
repayment of money borrowed for any purpose; charge accounts and credit card payments; doctor or hospital bills; taxes owed; etc. Do not include expenses (such as mortgage
payments) already listed in Section V, exclusive of item 10. Note: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay
in Section X.
(A) Name and Address of Creditor

(C) Original
Amount of Debt

(B) Purpose of Debt

Total

(E) Amount
Due Monthly

(D) Unpaid Balance

$

$

$

$

$

$

(F) Scheduled Date
of Full Repayment

Section VIII - Assets
Type of Asset
1. Cash on hand

Value

$

Type of Asset

Value

*6. Individual Retirement Accounts

$

2. Checking account(s). Give name and address of
financial institution(s) below

$
$

7. Debts owed to you (give name of debtor)

$

$
3. Savings account(s). Give name and address of
financial institution(s) below

*8. Vehicles
Type of Vehicle

Make

Model

Resale Value

Year

$
$

$

*4. Other interest-bearing account(s)

$
$

$
*5. Stocks, bonds, and other securities
(itemize below or in Section X)

$
$

$
$
$

*10. Other assets (itemize in Section X)
11. Total assets (total of lines 1 thru 10)

*See "Detailed Instructions" for an explanation of this item.

$
$

Section IX - Additional Data
If "Yes", give details in Section X.

Yes

No

1. Is anyone holding money or assets on your behalf?
2. Is there any likelihood that you will receive an inheritance or benefits from a trust?
3. Do you have any of the incorrectly paid checks in your possession?
(If "Yes", show the total amount and return the checks immediately.)

$

Section X - Remarks
Use this space and additional sheets if necessary to supply any other pertinent information and to continue your answers to previous items. Indicate section and item number to
which your comments apply.

Section XI - Certification
I affirm that the information provided herein is true, correct, and complete to the best of my
knowledge and belief.
1. Your signature

2. Date (mm/dd/yyyy)

Warning
Any intentionally false statement, concealment of material fact or
willful misrepresentation relative to this questionnaire is punishable
by a fine of not more than $10,000 or imprisonment for not more
than 5 years, or both (18 U.S.C. 1001). You may be asked to furnish
verification of any statement you make.

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. CFR, Part 831, Subparts M and N, and Part 845, which, discuss recovery of overpayments and
standards for waiver. 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 collect detailed financial information to determine whether to agree to a waiver, compromise, or
adjustment of the collection of erroneous payments from the Civil Service Retirement and Disability Fund. 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 to OPM is voluntary. However, failure
to provide this information may result in an unfavorable decision or financial investigation of the person who owes the United States.

Public Burden Statement
We estimate this form takes an average 60 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
(OPM), Retirement Services Publications Team (3206-0167), Washington, D.C. 20415-0001. The OMB number, 3206-0167 is currently valid. OPM may not collect this
information, and you are not required to respond, unless this number is displayed.