RI 34-20 Notice of Amount Due Because of FEHB Premium Underpaymen

United States
Office of Personnel Management
Retirement Operations
Washington, D.C. 20415

OMB Approval 3206-0167

Part 1
Notice of Amount Due Because of
FEHB Premium Underpayment

A COLLECTION IS SCHEDULED FROM YOUR ANNUITY BECAUSE YOU HAVE UNDERPAID FEDERAL EMPLOYEES HEALTH
BENEFIT PREMIUMS. Based on the explanation shown in box 9 below, the Office of Personnel Management (OPM) has determined that insufficient
premiums were withheld from your annuity to pay for the coverage you elected under the Federal Employees Health Benefits (FEHB) Program. This
underpayment of premiums is an amount you owe and we intend to collect it by offset from your annuity. The total amount is shown in box 5 below and the
proposed collection schedule is shown in boxes 6 and 7.
1. Retirement claim number

CSA
2. Case name
3. This notice dated
4. Request reconsideration/waiver by
5. Total to be collected

6. First installment to be collected from payment dated

Collection
Schedule

____ installments of
and
a final installment of

8. Period during which the underpayment accrued
From (mm/dd/yyyy)

7. Number of installments

9. Cause of underpayment
To (mm/dd/yyyy)

No premiums were withheld.
Incorrect premium amount was withheld.

If you wish to make payment in full, see Part 2.
Your Rights Concerning This Underpayment of Premiums
Before we can begin collection, we must tell you about your rights.
You or an individual you have authorized in writing to represent you may
personally inspect and copy our records pertaining to the underpayment at
our office in Washington, DC. Alternatively, you or your representative
may ask for a copy of our records. You must request an appointment for
personal inspection or a copy of the pertinent records on Part 2 of this form.
A. INSTALLMENTS COLLECTED AS SHOWN ABOVE OR
PAYMENT IN FULL (INSTRUCTIONS FOR PART 2A OF THIS
FORM). If you accept our decision concerning the existence and amount
of the underpayment, and agree to the installment withholding schedule
shown in blocks 6 and 7, you do not need to take any action. Payments will
automatically be deducted from your annuity as shown.
If you accept our decision concerning the existence and amount of the
underpayment, but do not want to pay in installments, you may check box 1
or 2 on Part 2 of this form and make payment in full as indicated.
1. Full Payment Enclosed (Check box 1 on Part 2 of this form)
If you are making
a full payment, send
your check or money
order to:

3. Lower Installments (Check box 3 on Part 2). You can ask OPM to
increase or decrease the amount of the installment we plan to deduct
(block 7 on Part 1 of this form) from your annuity. If you ask that the
installments be decreased, you must also indicate the amount you think
you can pay monthly. Also, complete the enclosed Financial Resources
Questionnaire for FEHB Premium Underpayments to show that lower
installments are necessary. (Note: You do not need to fill out the Financial
Resources Questionnaire to request lower installments as long as your
payments are at least $50 a month and are sufficient to pay off the entire
amount within 3 years.) We will do our best to accommodate your
financial situation. However, we cannot guarantee that the amount you
specify will be approved.
4. Compromise (Check box 4 on Part 2 of this form). Based on the
evaluation of your Financial Resources Questionnaire, if we determine that
you cannot pay the full amount within a reasonable period of time, we may
suggest a compromise. A compromise, in most instances, will involve our
acceptance of less than the total amount as full settlement for our claim.
(See 31 CFR 902.1, et seq.)
You can suggest a compromise of your own. We prefer that such offers not
involve installment payments. Rather, your compromise offer could be, for
example, an offer to pay a smaller lump sum now in full settlement of an
underpayment we set up for recovery over a period of months.

Office of Personnel Management
Attn: Legal Reconsideration Branch
1900 E Street, NW - Room 2H31
Washington, DC 20415

2. Full Payment Within 90 Days (Check box 2 on Part 2). We will allow
a maximum of 90 days to make full payment. You should specify the date
when payment will be mailed in the space provided. If payment has not
been received within 30 days after the date you specify, we will begin
installment deductions as indicated in blocks 6 and 7 on Part 1 of this form.
B. LOWER INSTALLMENTS OR COMPROMISE
(INSTRUCTIONS FOR PART 2B OF THIS FORM). If you accept
our decision concerning the existence and the amount of the underpayment,
but want to request lower installments or make a compromise payment
offer, check the appropriate box in Part 2B and submit any supporting
documents or statements requested.

We will consider compromise offers involving installment payments.
However, you must be willing to sign a firm written offer of compromise.
Your offer of compromise must be for a specific dollar amount with a
specific payment schedule. In order to have your compromise offer
considered, state in the space provided on the back of Part 2 all the reasons
why you believe compromise would be appropriate given your
circumstances, and complete the Financial Resources Questionnaire for
FEHB Premium Underpayments. You must establish your eligibility for
compromise by substantial evidence. (Note: We consider substantial
evidence to be sufficient relevant evidence supporting your conclusion to
make a reasonable person decide in your favor.)

Part 1 - For your records
Previous editions are not usable.

RI 34-20
Revised July 2022

C. RECONSIDERATION, WAIVER, LOWER INSTALLMENTS,
COMPROMISE, OR VOLUNTARY PAYMENT AGREEMENT
(INSTRUCTIONS FOR PART 2C OF THIS FORM). If you do not
accept our decision on the existence and/or amount of the premium
underpayment, you may request any of the options described below.
You may request more than one option. You should check the appropriate
box in Part 2C of this form and submit the supporting documents and
statements requested.
If we determine that the decision on the existence and/or amount of the
underpayment is correct, you have the right to appeal our decision in
United States Federal District Court. If we deny your request for waiver
or compromise, you may appeal our decision to the United States Merit
Systems Protection Board.
5. Reconsideration (Check box 5 on Part 2 of this form). You can
request reconsideration of our decision that you owe us or that the amount
you owe equals the amount shown in box 5 above. Show in the space
provided on the back of Part 2, all the reasons you believe that you do not
owe us or that the amount is incorrectly computed. (See 5 CFR 831.1304
for CSRS annuitants or 5 CFR 845.204 for FERS annuitants.)
6. Waiver (Check box 6 on part 2 of this form). Your request that OPM
waive (i.e., excuse payment of) the underpayment collection must be
submitted by the date shown in block 4 at the top of this notice. You
must prove by substantial evidence that (1) you were not at fault and (2)
collection of the underpayment amount would be against equity and good
conscience. (See 5 CFR 831, Subparts M and N for CSRS annuitants or 5
CFR 845 Subpart C for FERS annuitants.)
• Fault. To support your waiver request, you must provide substantial
evidence that your action (or failure to take a necessary and timely
action) did not play a part in causing or increasing the underpayment.
In making our decision, we will look at the issues explained below
in light of such mitigating factors as your age, physical or mental
condition, the nature of the information supplied to you regarding the
circumstances leading to the underpayment, etc. (Note: By itself, the
fact that OPM may have been responsible for the underpayment does
not necessarily mean that you will be excused from making repayment.
See "Equity and Good Conscience.")
• Considerations in Finding Fault. If you are submitting a request for
waiver, make sure you respond specifically to any of the questions
below that may apply to your underpayment:
a) If the underpayment occurred because of incorrect information you
furnished, would a reasonable person in your circumstances know
that the information was incorrect?
b) If the underpayment occurred because of your failure to provide
material information in your possession, would a reasonable person
in your circumstances know that he or she had to provide the
information and that failure to do so would make a difference in the
premium?
c) If OPM made the error in your payment, should a reasonable person
in your circumstances have known the payment was wrong?
• Equity and Good Conscience. Your submission in support of your
waiver request must provide substantial evidence to establish one or
more of the following:
a) Collection of the underpayment would cause you financial hardship.
We will find that financial hardship exists to a degree that will entitle
you to a waiver if you can show on your Financial Resources
Questionnaire for FEHB Premium Underpayments that you need
substantially all of your current income and liquid assets to meet
ordinary and necessary living expenses and liabilities. Note:1) in
making this decision, we are primarily concerned with your ability to
pay us now. However, we will also consider whether your financial
condition can be expected to improve in the future. 2) If the expenses
shown on the Financial Resources Questionnaire include those of
your spouse and children, the income section must also include the
income generated by those members of your family.
b) When you received your annuity with the insufficient premiums
withheld, did it (regardless of your current ability to pay) cause you
to give up a valuable right, such as some other benefit payment. Or,
in reliance on the incorrect payment, did you change your financial
position for the worse, such as making a commitment that you would
not have made under other circumstances.

c) Collection of the premium underpayment would otherwise be
inequitable due to special or exceptional circumstances. (Note: In the
event we determine that the underpayment exists, the amount owed is
correct, and your waiver or compromise request is denied, we may still
consider lessening the financial burden by lowering your monthly
installments. For this purpose, you should indicate on Part 2 of this
form the amount you can pay on a monthly basis to pay in full.)
7. Lower Installments Or A Compromise Payment (Check the appropriate
box in item 7 on Part 2 of this form). In the event your reconsideration or
waiver request is denied, you may also request lower installments or offer a
compromise payment. Make, on the back of Part 2, the statements required
to support your request (see the discussion of "Lower Installments" and
"Compromise" in Part 1, item 4), and complete the Financial Resources
Questionnaire for FEHB Premium Underpayments.
8. Voluntary Payment Agreement (Check box 8 on Part 2 of this form).
Rather than having your annuity offset, you may ask us to let you send in
regular installment payments. We have sole discretion whether to accept such
payments in place of the offset. If you want to send your payments to us instead
of having them deducted from your annuity, you must complete Part 2 of this
form. In the space titled "Your Statement Concerning the Underpayment of
FEHB Premiums" show that deducting monthly installments from your annuity
would cause a financial hardship or would be against equity and good conscience.
You must also complete the Financial Resources Questionnaire for FEHB
Premium Underpayments. Do not make payments until we notify you that the
voluntary payment agreement is acceptable. If we approve the voluntary payment
agreement and your account becomes delinquent, we will cancel the payment
agreement and make deductions from your annuity until the amount is paid.
D. HOW AND WHEN TO MAKE YOUR REQUEST. The procedures
for requesting copies of your records, lower installments, a voluntary
payment agreement, reconsideration, waiver, or compromise are as follows:
1. Complete Part 2 of this form and state your reasons for making the
request(s). If your name and address as shown are not correct, make any
necessary changes.
2. If your request is returned to us by mail, it must be postmarked within
30 calendar days after the date of this notice (see box 3) and mailed to:
Office of Personnel Management
Attn.: Legal Reconsideration Branch
1900 E Street, NW - RM 2H31
Washington, DC 20415

3.

If you hand deliver your request, bring it to:
Office of Personnel Management
Attn.: Retirement Information Office
1900 E Street, NW - Room 1323B
Washington, DC 20415

4.

OPM can extend the 30-day time limit only if you show that you were
not aware of the time limit or you were prevented from responding by a
cause beyond your control.
If you plan to submit additional evidence to support your request and that
information is not available, you must:
• Submit Part 2 of this form within the 30-day time limit; and
• Include in your request a statement that you will be submitting additional
evidence, a brief description of the evidence that you will submit, your
estimate of the date the evidence will be available, and a brief
explanation for the delay.
We will acknowledge receipt of your statement and consider your request
filed on time. Please send the additional evidence as soon as possible.
E. FINAL DECISION. After we consider your request, we will send you a
final decision in writing. If our decision is not in your favor, any further
rights of review available to you will be explained at that time. Collection
actions will be suspended at all levels of review if a timely request is
received, unless you become eligible for a lump sum payment or your
recurring monthly payment is scheduled to cease within one year and (1)
failure to make offset would substantially prejudice the Government's ability
to collect and (2) the time before the payment is to be made does not permit
completion of the proceedings explained above.

RI 34-20
Revised July 2022

United States
Office of Personnel Management
Retirement Operations
Washington, D.C. 20415

OMB Approval 3206-0167

Part 2
Request for Lower Installments, Voluntary Payment
Agreement, Reconsideration, Waiver, And/Or Compromise
When An Underpayment of FEHB Premiums Was Made
From The Civil Service Retirement and Disability Fund

1. Retirement claim number

CSA
2. Case name
3. This notice dated
4. Request reconsideration/waiver by
5. Total to be collected

6. First installment to be collected from payment dated

7. Number of installments

Collection
Schedule

____ installments of
and
a final installment of

8. Period during which the underpayment accrued
From (mm/dd/yyyy )

9. Cause of underpayment
To (mm/dd/yyyy)

No premiums were withheld.
Incorrect premium amount was withheld.

Check the box or boxes that apply to you. You may check more than one box, unless you check boxes A.1 or A.2.
A.

B.

I accept the decision on the existence and amount of the underpayment, and I agree to make payment in full. I will not make partial payments.
I agree to make -1.

Full Payment

2.

Full Payment
Within 90 Days

My check or money order, payable to the U.S. Office of Personnel Management in the amount of
$_______________________ is enclosed. Send to: OPM, Attn: Legal Reconsideration Branch, 1900
E Street, NW, Room 2H31, Washington, DC 20415.
I will send my check or money order payable to the U.S. Office of Personnel Management in the amount of
$________________________ on or before ______________________.

I accept the decision on the existence and amount of the underpayment, but I request -3.

Lower Installments

I request lower installments. I understand that OPM generally expects to be paid within 36 months and that each
installment be at least $50 per month. I have indicated below the amount I can pay each month.
My financial resources will allow me to have $_____________ per month deducted from my annuity. I am
submitting the Financial Resources Questionnaire for FEHB Premium Underpayments and my statement on the
reverse to support my request.

4.

C.

Compromise

I propose a compromise payment. I have indicated the amount and terms of my offer on the reverse. I am
submitting the Financial Resources Questionnaire for FEHB Premium Underpayments and my statement on the
reverse to support my request. I understand that I must establish by substantial evidence that I am unable to repay
the full amount within a reasonable time.

I do not accept your decision to recover this underpayment from my annuity and I request -5.

Reconsideration of the
Existence or Amount
of the Underpayment

I am providing the specific reasons for my disagreement with your decision on the reverse. If the existence
and/or the amount of the premium underpayment is confirmed, I understand that the money will be collected as
shown in block 7 above, unless my request for waiver, lower installments, or a compromise is approved.

6.

Waiver

I am submitting the Financial Resources Questionnaire for FEHB Premium Underpayments (unless my waiver
request is not based on financial hardship) and my statement on the reverse to support my request. I understand
that I must establish by substantial evidence that I am eligible for a waiver.

7.

Lower Installments
or a Compromise
Payment

If the existence and/or the amount of underpayment is confirmed or my waiver request is denied, I also request
consideration for
lower installments in the amount of $__________________ per month
a compromise
payment as shown on the reverse. (Please check the applicable box.) I am submitting the Financial Resources
Questionnaire for FEHB Premium Underpayments and my statement on the reverse to support my request.

8.

Voluntary Payment
Agreement

I am submitting the Financial Resources Questionnaire for FEHB Premium Underpayments and my statement on
the reverse to support my request.

Remember, in the event that we determine (1) the underpayment exists and the amount owed is correct and (2) your request for a voluntary payment
agreement, waiver, or compromise is denied, we may consider alleviating the financial burden of payment by lowering your monthly installments. Be sure to
tell us what you can pay in your response to item C.7. above.
Part 2 - Use this form if you wish to request lower installments, a voluntary payment agreement, reconsideration, waiver, or compromise.
RI 34-20
Revised July 2022

Your Statement Concerning The Underpayment of FEHB Payments
(Attach additional pages if necessary)

Your signature

Telephone number (including area code)

Email Address

Date

Mail to:

Office of Personnel Management
Attn: Legal Reconsideration Branch
1900 E Street, NW - Room 2H31
Washington, DC 20415
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 inform the annuitant about the overpayment and collects information from the annuitant about how repayment will be made.
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 of 60 minutes 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, DC 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.

Reverse of Part 2

RI 34-20
Revised July 2022