Form RI 92-19 RI 92-19 Application for Deferred or Postponed Retirement: FERS

Application for Deferred or Postponed Retirement
Federal Employees Retirement System

OMB Approval 3206-0190

This application is for you if you are a former Federal employee who was covered by the Federal Employees Retirement System (FERS) and
you wish to apply for your retirement annuity. You should complete this application if you choose to apply for an annuity which will begin
more than 1 month after your separation from Federal service (or transfer to a position not covered by FERS) and:
1.

you have completed at least 5 years of creditable civilian service and are eligible for a deferred retirement at age 62; or

2.

you have completed at least 10 years of creditable service, including 5 years of civilian service, and are eligible for an annuity at the
Minimum Retirement Age (MRA).

Send your completed (approximately 60 days before you want your benefits to begin) to:
Office of Personnel Management
Federal Employees Retirement System
P.O. Box 45
Boyers, PA 16017-0045

An informational pamphlet RI 92-19A, Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement System,
is available on our website at www.opm.gov/Forms/. You can also get a copy by calling the Office of Personnel Management (OPM) at
1-888-767-6738 or by contacting us at the address above. Hearing impaired users should utilize the Federal Relay Service by dialing 711
or your local communications provider to reach a Communications Assistant.
If your address changes before you receive your claim number, write to us giving your name, date of birth and social security number.
If you have received your claim number, remember to refer to it.

Instructions for Completing Application for Deferred or Postponed Retirement
Type or print clearly. If you need more space in any section, use a
plain piece of paper with your name, date of birth, and Social
Security Number written at the top. If you do not know an answer
write “unknown.” If you are uncertain of any information you
provide, answer to the best of your ability, followed by a question
mark (?).
The following information should help you to answer the questions
on the application which are not self-explanatory.

Section C - Military Service
Item 1:

Indicate whether you have performed active duty that
terminated under honorable conditions in the armed
services or other uniformed services of the United
States, including the following:
●

Army, Navy, Marine Corps, Air Force, or Coast
Guard of the United States.

●

Cadet at the United States Military Academy,
United States Air Force Academy, United States
Coast Guard Academy, or Midshipman at the
United States Naval Academy.

●

Regular Corps or Reserve Corps of the Public
Health Service after June 30, 1960.

●

Commissioned Officer of the National Oceanic and
Atmospheric Administration after June 30, 1961 or
a predecessor entity in function.

Section A - Identifying Information
Item 2:

Item 4:

List other names under which you have been employed
in the Federal government (such as a maiden name).
This will help us to locate and identify all your records.
Enter the address to which correspondence should be
mailed. Do not enter the bank address where your
payments will be deposited here; complete Section H of
this application.

Section B - Federal Civilian Service
Item 2:

Show the agency where you performed your last
Federal service. Give the bureau and/or division as
well as the name of the agency and include its location
(city, state).

Item 3:

List all Federal civilian service that you have
performed. Give the bureau and/or division as well as
the name of the agency, along with the agency’s
location and the beginning and ending dates of the
service. If you need more than 5 lines, write "See
Attached" in Part B of the form. Use a blank sheet.
Print your name, date of birth and social security
number at the top of the attachment. Also, list the
Department or Agency, Location (City and State) and
Dates (From and To).

Previous editions are not usable

Excluding the National Guard, active service in the reserve
components of the uniformed services, including active duty for
training, is military service. Service as a National Guard member
does not meet the definition of military service for purposes of
civil service retirement, except when the member is ordered to
active duty in the service of the United States or performs full-time
National Guard duty (as such term is defined in Section 101(d) of
title 10) if the National Guard duty interrupts creditable civilian
service under Subchapter I of Chapter 84 of title 5, and is followed
by reemployment in accordance with Chapter 43 of title 38 that
occurs on or after August 1, 1990.

Instruction Page 1, RI 92-19
Revised October 2022

Item 2:

Item 4:

Persons who performed active military service after
December 31, 1956, must have paid a deposit to receive
credit under the Federal Employees Retirement System
(FERS) for their military service. You must have paid
your your deposit while you were still a Federal
employee, you cannot pay it now. If you have military
service performed after 1956, which is covered by a
deposit you paid as an employee, check “Yes” and
continue with this section. Items 2a and 2b will help us
locate records of your payment.

Section D - Other Claim Information
Item 3:

The information requested regarding benefits from the
OWCP is needed because the law prohibits payment of
both FERS retirement annuity and compensation for
total or partial disability under the Federal Employees’
Compensation Act at the same time. In some cases,
credit for service, particularly for periods of leave
without pay, may also be affected.

Indicate whether you are receiving or have applied for
military retired or retainer pay (including disability
retired pay and reserve retainer pay).
If you are receiving military retired pay, your military
service cannot be used for retirement purposes unless
your retired pay was awarded because of a serviceconnected disability incurred in combat with an enemy
of the United States or caused by an instrumentality of
war and incurred in the line of duty during a period of
war as defined by Section 1101 of title 38, or was
awarded under Chapter 1223, title 10, formerly Chapter
67, title 10 and title III of Public Law 80-810 (reserve
retired pay at age 60 based on 20 years of active
and reserve service). Otherwise, to receive credit for
your military service, you must waive your military
retired pay.
To waive military retired pay for FERS retirement
purposes, send a written request, specifying the
effective date of the waiver and your Social Security
Number, directly to the Military Finance Center from
which you receive retired pay. Attach a copy of your
letter to this application. You should mail this letter
at least 60 days before your annuity will begin.
Your letter might say, “I, (full name, military serial
number, and Social Security Number), hereby waive
my military retired pay for FERS retirement purposes,
effective close of business (specify the day before
annuity begins).” If you wish, add “I authorize the
Office of Personnel Management to withhold from
my retirement annuity any amount of military pay
granted beyond the effective date of this waiver due
to any delay in receiving or processing this election.”
This authorization may hasten the processing of your
waiver and your retirement application.
If you have already waived military retired pay in order
to receive credit for your active military service for
FERS retirement purposes, attach a copy of your
request for waiver and of any reply you have received.
Obtain counseling from the military before waiving
military retired pay for FERS retirement if you receive
or may receive Combat Related Special Compensation
(CRSC) or concurrent receipt of military retired pay
and veterans compensation.
Reminder: Even if you have waived military retired
pay or qualify for one of the exceptions to waiver, you
must have paid a military deposit for your military
service performed after 1956 to receive credit for the
service in your FERS annuity, and the military deposit
must have been paid to your employing agency before
you separated from FERS covered Federal employment.

If you have applied for or have ever received workers’
compensation from the Office of Workers’
Compensation Programs (OWCP), U.S. Department
of Labor, because of a job-related illness or injury,
check the “Yes” box and furnish your claim
number(s), type(s) of benefits, and date(s) of benefits
in 3a, 3b and 3c.

Section E - Marital Information
Item 2:

Indicate whether you have a living former spouse to
whom a court order awards a survivor annuity or a
portion of your retirement benefits based on your
Federal employment. If you answer “Yes,” you must
submit a copy of the divorce decree and any
attachments or amendments.

Section F - Annuity Election
Read the information about survivor benefits and their associated
cost found in the pamphlet “Applying for Deferred or Postponed
Retirement Under the Federal Employees Retirement System”
(RI 92-19A) before completing Section F.
To be eligible for a survivor annuity after your death, your spouse
must have been married to you for a total of at least 9 months or be
a parent of your child. The marriage duration requirement does not
apply if your death is accidental. Attach a copy of your marriage
certificate.
Survivor elections terminate upon the death of the person elected.
An election of a survivor annuity for a current spouse in box 1 or 2
also terminates upon a divorce from that spouse. An election of a
survivor annuity for a former spouse in box 5 also terminates if
that former spouse remarries before age 55, unless the annuitant
and the former spouse were married for 30 years or more. You
must notify us when one of those events terminating a survivor
election occurs. Also notify us if a former spouse who is entitled
to a survivor annuity under a court order acceptable for processing
becomes ineligible for the former spouse annuity because of a
reason specified in the court order or because of a remarriage
prior to age 55.
Please note that, in accordance with the law, both a survivor
annuity election made at retirement and survivor annuity election
made before a divorce, terminate upon death or divorce and the
annuitant must make a new election (reelection) within 2 years
after the terminating event to provide a survivor annuity for a
spouse acquired after retirement or for a former spouse.
Continuing a survivor reduction, by itself, is not effective to
reelect a survivor annuity for a spouse married after retirement
or for a former spouse.

Reverse of Instruction Page 1, RI 92-19
Revised October 2022

Item 4:

If you initial box 4, a person selected by you at
retirement who has an insurable interest in you, will
receive a survivor annuity upon your death. Enter the
requested information about that person. Insurable
interest exists if the person named (such as a close
relative) may reasonably expect to derive financial
benefit from your continued life.
You must provide documentation that you are in good
health in order to choose this type of annuity. You will
be notified of the additional evidence required.
If you choose this type of annuity, the amount of the
reduction in your annuity will depend upon the
difference between your age and the age of the person
named as survivor annuitant, as shown in the following
table. The survivor’s rate will be 55% of your reduced
annuity.
Age of the Person Named
in Relation to
That of
Retiring Employee

Reduction in
Annuity of
Retiring
Employee

Older, same age, or less than 5 years younger

10%

5 but less than years 10 younger

15%

10 but less than 15 years younger

20%

15 but less than years 20 younger

25%

20 but less than 25 years younger

30%

25 but less than years 30 younger

35%

30 or more years younger

40%

You may elect this insurable interest survivor annuity in
addition to a regular survivor annuity for a current or
former spouse. However, if you elect an insurable
interest annuity for your current spouse, you must both
jointly waive the current spouse annuity. Generally, an
insurable interest annuity cannot be cancelled.
However, if you elect an insurable interest annuity for
your current spouse because a former spouse is entitled
to the regular survivor annuity (under a court order
acceptable for processing or based on your election of
that survivor benefit for the former spouse), you can
convert the insurable interest election for your current
spouse to a current spouse annuity within two (2) years
of the former spouse losing entitlement to the regular
survivor annuity.
Item 5:

If you initial box 5, your former spouse(s) will receive a
survivor annuity upon your death. The maximum
survivor annuity payable to your former spouse(s) is
50% of your unreduced annuity. Your annuity will be
reduced 5% or 10% according to the total benefit you
want to provide.

Section G - Information About Children
Complete Section G by providing the names and dates of birth of
your unmarried dependent children under the age of 22. Also list
any child over the age of 22 who is incapable of self-support
because of mental or physical disability incurred before the age
of 18. Check the box headed “disabled” by the name of each
child to whom this applies. Information about your children in
your annuity claim file may help to expedite the processing of
claims for survivor benefits when you die.

Section H - Payment Instructions
Complete in all cases. The US Department of the Treasury pays all
Federal benefit payments electronically. Most Federal payments
are paid by Direct Deposit into a savings or checking account at a
financial institution. If you do not have a bank account, or prefer
not to have your annuity payments deposited directly to your bank
account, you can choose a Direct Express debit card. If you choose
this option, your annuity payment will be automatically deposited
to the Direct Express card on the payment date. To obtain a debit
card, go to www.godirect.gov or call 1-800-333-1795. If your
payments are not electronically deposited to your account and
you do not have a Direct Express card, you must contact the
Department of Treasury at 1-800-333-1795.
You cannot receive your annuity payments by direct deposit or the
Direct Express debit card program if your permanent payment
address is outside the United States in a country where these
programs are not available.
Item 2:

You may obtain your Financial Institution Routing
Number by calling your bank, credit union, or savings
institution. This number is very important. We cannot
pay by direct deposit without it. We suggest you call
your financial institution to verify this number.

If you prefer, you may attach a cancelled personal check that
shows the information requested instead of filling in the
requested financial institution information. If you attach your
personal check, it is especially important that you contact your
bank, credit union, or savings institution to confirm that the
information on the check is correct information for direct deposit.
(Some financial institutions, especially credit unions, use
different routing numbers on checks.) We can then use this
information to start paying you by direct deposit.

Section I - Applicant's Certification
Be sure to sign (do not print) and date your application after
reviewing the warning.

If you are married and initial box 5, you must complete
and attach Schedule A - Spouse’s Consent to Survivor
Election, to your application. The law requires consent
of the spouse if a married person elects a full or partial
survivor annuity for a former spouse. You may not elect
a combined benefit for your current and former
spouse(s) which exceeds 50% of your benefit.
Instruction Page 2, RI 92-19
Revised October 2022

Schedules (Attachments)

If your year of birth is:

There are three schedules attached to this application for deferred
or postponed retirement. Some of these schedules may apply to
you and some may not. Read the following to determine which
schedules you should complete. Instructions for completing and
information about each follows.

Schedule A - Spouse's Consent to Survivor Election
Complete this schedule if you are married and, in Section F, you
do not elect box 1, a maximum survivor annuity for your spouse.
For any other election you must obtain your spouse’s consent.
(See the pamphlet entitled “Applying for a Deferred or Postponed
Retirement Benefit Under the Federal Employees Retirement
System" [RI 92-19A] for information about asking the Office of
Personnel Management (OPM) to waive the spousal consent
requirement in special circumstances.)
Part 1:

Before 1948

55 years

1948

55 years, 2 months

1949

55 years, 4 months

1950

55 years, 6 months

1951

55 years, 8 months

1952

55 years, 10 months

1953 to 1964

56 years

1965

56 years, 2 months

1966

56 years, 4 months

1967

56 years, 6 months

1968

56 years, 8 months

1969

56 years, 10 months

After 1969

57 years

You must complete this section. Include your name,
date of birth and Social Security Number as shown on
your application. Check the box(es) that corresponds to
the selection(s) you made in Section F on your
application. Check all boxes that apply.

Schedule B

Part 2:

Your spouse completes this section, in the presence of a
notary public.

2.

Part 3:

A notary public or other person authorized to
administer oaths (e.g., a just of the peace) must
complete this section, after witnessing your spouse's
signature.

Part 2:

If you have at least 10 years of creditable service (5 of which must
be civilian) which will be used to compute your benefit, then you
must complete one of these two schedules. Do not complete either
of these schedules if you have less than 10 years of service.

Complete Schedule C if you had not yet attained the MRA when
you left Federal service, but you did have at least 10 years of
creditable service. You are eligible to choose when you want
your benefit to begin.
The MRA is based on the year of your birth and determines the
earliest date you became eligible to have your retirement annuity
begin. The Minimum Retirement Age Schedule is:

You may choose too have your annuity begin on:
1. the first day of the month following your
separation from Federal service; or
the first day of any month which is at least 31 days
after the Office of Personnel Management (OPM)
receives your application for retirement (but before
your 62nd birthday).
Your annuity will be reduced by 5/12 of 1% for
each full month (5% per year) that the date your
annuity begins or precedes your 62nd birthday.
You can avoid the age reduction entirely if you
choose the first day of the month that you reach
age 62 as your annuity commencing date.
The age reduction does not apply if your annuity
commences the first day of the month after your
60th birthday and you have at least 20 years of
service.

Schedules B & C - For Applicants Who Have At Least 10
Years of Creditable Service

Complete Schedule B if you had attained the Minimum Retirement
Age (MRA) when you left Federal service and had at least 10 years
of creditable service. You are eligible to choose when you want
your benefit to begin and may be eligible to reenroll in the health
benefits, life insurance and Federal Dental and Vision programs
and carry them into retirement.

Your MRA is:

Part 3
and 4:

People who leave Federal service after reaching the
MRA with at least 10 years of creditable Federal
service are eligible to reenroll in the Federal Employees
Health Benefits Program and the Federal Employees’
Group Life Insurance Program if they had participated
in the program for the 5 years of service immediately
before their separation date or continually from their
earliest opportunity. If you were enrolled in either of
these programs when you left Federal employment
and you had already attained your MRA and had 10
years of creditable service, complete these sections.
If you want information about reenrolling in either
program, indicate so in item 1b.

Reverse of Instruction Page 2, RI 92-19
Revised October 2022

Part 5:

Part 6:

People who leave Federal service after reaching the
MRA with at least 10 years of creditable Federal
service are eligible to reenroll in the Federal Dental
and Vision Insurance Program (FEDVIP). If you were
enrolled in FEDVIP when you left Federal employment
and you had already attained your MRA and had 10
years of creditable service, complete this section.
If you want information about reenrolling, indicate so
in item 1b.
If you are enrolled in the Federal Long Term Care
Insurance Program (FLTCIP), your coverage will
continue. No action is required by you. However, you
may choose to have your premium payments deducted
from your annuity. To elect annuity deduction of
premiums, please call Long Term Care Partners, at
1-800-582-3337. Hearing impaired users should
utilize the Federal Relay Service by dialing 711 or
their local communications provider to reach a
Communications Assistant.

Your annuity will be reduced by 5/12 of 1% for
each full month (5% per year) that the date your
annuity begins or precedes your 62nd birthday.
You can avoid the age reduction entirely if you
choose the first day of the month that you reach
age 62 as your annuity commencing date.
The age reduction does not apply if:
a) Your annuity commences the first day of the
month after your 60th birthday and you have
at least 20 years of service, or
b) Your annuity commences the first day of the
month after you reach your MRA and you have
at least 30 years of services
Part 3:

If you are not currently enrolled in the FLTCIP, you,
your spouse, and your adult children may apply for
FLTCIP coverage provided you are eligible for a
deferred or postponed annuity. You may request an
application by calling Long Term Care Partners, at
1-800-582-3337. Hearing impaired users should utilize
the Federal Relay Service by dialing 711 or their local
communications provider to reach a Communications
Assistant or by visiting www.ltcfeds.com.

Schedule C
Part 2:

You may choose to have your annuity begin on:
1. the first day of the month following the month in
which you reach your MRA; or
2.

If you are enrolled in the Federal Long Term Care
Insurance Program (FLTCIP), your coverage will
continue. No action is required by you. However,
you may choose to have your premium payments
deducted from your annuity. To elect annuity deduction
of premiums, please call Long Term Care Partners,
at 1-800-582-333. Hearing impaired users should utilize
the Federal Relay Service by dialing 711 or their local
communications provider to reach a Communications
Assistant.
If you are not currently enrolled in the FLTCIP, you,
your spouse, and your adult children may apply for
FLTCIP coverage provided you are eligible for a
deferred or postponed annuity. You may request an
application by calling Long Term Care Partners, at
1-800-582-3337. Hearing impaired users should utilize
the Federal Relay Service by dialing 711 or their local
communications provider to reach a Communications
Assistant or by visiting www.ltcfeds.com.

the first day of any month which is at least 31 days
after OPM receives your application for retirement
if you have reached your MRA (but before your
62nd birthday).

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. Code Chapters 84, which, provides
for both immediate and deferred retirement benefits, depending on the individual’s age and total service at separation. 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 determine whether the applicant is eligible for a deferred or postponed annuity and to
compute the amount of the 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 noncompliance of the provisions of title 5, U.S.C, Chapter 84. Additionally, the award of benefits could
be delayed. Individuals who do not provide this information can also request changes via telephone or letter, as well as using RI 92-19.
The information collected can only be obtained from the respondents.

Public Burden Statement
We estimate that this form takes an average of 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 (3206-0190),
Washington, D.C. 20415-0001. The OMB number, 3206-0190, is currently valid. OPM may not collect this information, and you are not
required to respond, unless this number is displayed.
Instruction Page 3, RI 92-19
Revised October 2022

OMB Approval 3206-0190

Application for Deferred or Postponed Retirement
Federal Employees Retirement System
Section A - Identifying Information
1.

Name (last, first, middle)

2.

List all other names used

3.

Date of birth (mm/dd/yyyy)

4.

Address (number, street, city, state, ZIP Code)

5a. Daytime telephone number

5b. Best time to reach you

6.

Email address

7.

8.

Are you a citizen of the United States of America?

Social Security Number

Yes

No

Section B - Federal Civilian Service
1.

Date on which you separated from Federal service (mm/dd/yyyy)

2.

What agency did you separate from? (Give agency,group or office)

3.

List below all Federal service you have performed. If you need more room, write "See Attached" (for additional information, see Instructions, Section B, Item 3.)
Location (city and state)

Department or Agency, including Bureau or Division

Dates of Service
From (mm/dd/yyyy) To (mm/dd/yyyy)

Section C - Military Service
1.

Have you performed active, honorable service in the Armed Forces or other uniformed services of the United States? (See instructions for definition.)

Yes, go to item 2.
2.

No, go to Section D.

If you have military service performed after 1956, did you pay a deposit to your former employing agency?

Not applicable, go to item 3.

Yes, go to item 2a.

2a. When did you pay your deposit for post-56 military service?
(mm/dd/yyyy)
3.

If you have performed active, honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definition), complete 3a-3d below
and attach a copy of your discharge certificate or other certificate of active military service (if available).
3a. Branch of Service

3b. Serial Number

3c. Dates of Active Duty
From (mm/dd/yyyy)

4.

No, go to item 3.

2b. To which agency did you make the payment? (Give agency, bureau or division and location)

Are you receiving or have you ever applied for military
retired or retainer pay (including disability retired pay)?

3d. Last Grade or Rank

To (mm/dd/yyyy)

4a. Was your military retired or retainer pay awarded for disability incurred in combat or caused by an
instrumentality of war and incurred in the line of duty during a period of war?

Yes, complete items 4a-4c.

Yes, if available, attach a copy of notice of award.

No, go to Section D.

No

4b. Was your military retired or retainer pay awarded for reserve service under
Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10)?

4c. Are you waiving your military retired pay in order to receive credit for FERS?

Yes, if available, please attach a copy of notice of award.

Yes, see instructions for information about how to request a waiver.
Yes, a copy of my waiver is attached.

No

No

Office of Personnel Management
Previous edition is not usable

CSRS/FERS Handbook

Continued on reverse

RI 92-19
Revised October 2022

Section D - Other Claim Information
1.

Have you previously filed any application under the Federal Employees Retirement System or Civil Service Retirement System (for refund, retirement, deposit,
redeposit, etc.) ?

No

Yes (Complete 1a and 1b)
1a. Type of application

1b. Claim number(s)

Retirement
Refund
2.

Deposit/redeposit
Refund of excess deductions

Have you ever been employed under another retirement system for Federal or District of Columbia employees?

Yes (Complete 2a - 2e)

No

2a. Name of other
Retirement System

2b. Dates of Service
From (mm/dd/yyyy)

3.

2c. Location of
Employment

2d. Title of Position

To (mm/dd/yyyy)

2e. Were retirement
deductions withheld?
Refunded
Yes
No

Have you ever received workers' compensation from the Department of Labor because of a job-related illness or injury?

Yes, complete 3a thru 3c.
3a. Compensation Claim Number

No

3b. Description of benefit

Scheduled Award

3c. Date benefits
received

Total/partial disability
Other

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Section E - Marital Information
1.

Are you married? If separated from your spouse, but the marriage has not ended by divorce or annulment, answer "Yes."

Yes (Complete items 1a thru 1f and attach a copy of your marriage certificate.)
1a. Spouse's name (last, first, middle)
1d. Place of marriage (city, state)

Statement regarding
Former Spouses

No

1b. Spouse's date of birth (mm/dd/yyyy)
1e. Date of marriage (mm/dd/yyyy)

1f. Marriage
performed by

1c. Spouse's Social Security Number

Clergyman or Justice of the Peace
Other (explain)

2. Do you have a living former spouse(s) to whom a court order gives a survivor annuity or a portion of your retirement benefits based on your
Federal employment?

Yes

No

Section F - Annuity Election
Read the attached instructions before making this election.
Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested. Consider your election carefully. No change will
be permitted after your annuity is granted except as explained in the pamphlet Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement System,
RI 92-19A. If you are currently married and you do not elect maximum survivor benefits the law requires that your spouse consent to your election. Therefore, you must
complete Schedule A and attach it to this application.
Your election to provide a survivor annuity for a current spouse terminates upon the death of that spouse or if the marriage ends due to divorce or annulment. You are required to
make a new election (reelect) within 2 years of the terminating event if you wish to reelect a survivor annuity for a former spouse or within 2 years of a post-retirement marriage to
elect a survivor annuity for a spouse acquired after retirement. Continuing a survivor reduction, by itself, is not effective to reelect a survivor annuity for a spouse married after
retirement or for a former spouse.
If you want to elect a partial survivor annuity for your current spouse and a survivor benefit for a former spouse, you should complete options 2 and 5 below. The total of the
survivor annuities elected cannot exceed 50 percent. An election of an insurable interest survivor in option 4, is not included when determining the 50 percent maximum.
1.
I choose a reduced annuity with maximum survivor annuity for my spouse named in Section E.
If you are married at retirement you will automatically receive this type of annuity unless your spouse consents to your election not to
Initials

2.

provide maximum survivor benefits. If you receive this annuity, your annuity will be reduced by 10%. The survivor's annuity upon your
death will be 50% of your unreduced annuity.

I choose a reduced annuity with a partial survivor annuity for my spouse named in Section E.
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If you choose this option, your annuity will be reduced by 5%. Upon your death, your spouse's annuity will be 25% of your unreduced

annuity. You must have your spouse's consent to choose this option. Attach Schedule A showing your spouse's consent.
3.

I choose an annuity payable only during my lifetime.
No current spouse survivor annuity will be paid to your spouse after your death if he or she consents to this election. If you are married
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at retirement, you cannot choose this type of annuity without your spouse's consent. You should initial this box if you are electing
an insurable interest benefit (Box 4) for your current spouse. Attach Schedule A showing your spouse's consent. If you are eligible
to continue your health benefits coverage into retirement, your spouse's health benefits coverage will terminate upon your death.
In addition, your spouse will not be eligible to enroll in the Federal Long Term Care Insurance program, if he/she is not enrolled
at the time of your death.

4.

I choose a reduced with survivor annuity payable only during my lifetime.
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You must be healthy and willing to provide medical evidence if you choose this type of annuity.

Name of person with insurable interest

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Relationship to you

Date of birth (mm/dd/yyyy)

Social Security Number

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5.

I choose a reduced annuity with survivor annuity for my former spouse(s) as follows:
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You must attach: 1. Certified copies of divorce decrees for all former spouses for whom you elect to provide survivor annuity.

2.

If you are married, attach a completed Schedule A (Spouse's Consent to Survivor Election). You cannot choose
this option and provide a maximum survivor annuity for your spouse (Box 1).

Your election to provide a survivor annuity for a former spouse terminates upon the death of that spouse or the remarriage of your
former spouse before age 55 (unless your marriage to the former spouse lasted for 30 years or longer).
This election when combined with an election in Box 2 cannot exceed 50% of your unreduced annuity.
Persons who completed Box 1 may not complete Box 5.
Name and address of former spouse

Name and address of former spouse

Date of marriage (mm/dd/yyyy)

Date of divorce (mm/dd/yyyy)

Date of birth (mm/dd/yyyy)

Social Security Number

Date of marriage (mm/dd/yyyy)

Date of divorce (mm/dd/yyyy)

Date of birth (mm/dd/yyyy)

Social Security Number

Total (must equal either 25% or 50%)

Survivor annuity equal to this
percent of my annuity

%
Survivor annuity equal to this
percent of my annuity

%

%



Section G - Information About Your Unmarried Dependent Children
Dependent Child's Name
(first, middle, last)

Date of Birth
(mm/dd/yyyy)

Disabled



Dependent Child's Name
(first, middle, last)

Date of Birth
(mm/dd/yyyy)

Disabled



Section H - Payment Instructions
1.

Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department of
Treasury. See page 2 of the instructions for this application and RI 92-19A (Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement
System) for additional information. This does not apply to you if your permanent payment address is outside of the United States in a country not accessible via direct
deposit.
Please select one of the following:

Please send my annuity payments directly to my checking or savings account. (Go to item 2)
Please send my annuity payments to my Direct Express debit card. (Go to Section I)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to Section I)
2.

Please provide information about your financial institution below.

2a. Financial institution routing number
2b. Account number

2c. Name and address of financial institution

2d. Telephone number of your
financial institution (including
area code)

Checking
Savings

Section I - Applicant's Certification
Warning
I hereby certify that all statements made in this application are true to the best of my knowledge and that no evidence
Any intentionally false statement in this application necessary to the settlement of this claim is withheld. I have read and understand all the information provided in the
or willfully misleading statement or response you instructions to this application.
provide in this application is a violation of the law Signature (do not print)
Date (mm/dd/yyyy)
punishable by a fine of not more than $10,000 or
imprisonment of not more than 5 years or both
(18 U.S.C. 1001).

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Page 2, RI 92-19
Revised October 2022

Schedule A - Spouse's Consent to Survivor Election
Instructions - Complete this schedule if you are married and do not elect a reduced annuity to provide a full current spouse survivor
annuity. Complete Part 1. Have your spouse complete Part 2. Part 2 must be completed in the presence of a Notary Public or other
person authorized to administer oaths. The Notary Public must complete Part 3.

Part 1 - To Be Completed By the Applicant
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

I have elected (Mark all boxes which describe the survivor elections you have made.)

A.

No regular or insurable interest survivor annuity for my current spouse. I understand that:
●
●

No survivor annuity will be paid to my spouse after my death.
If I am eligible to continue my health benefits coverage into retirement, his/her health benefits coverage will terminate upon my death, and

●

He/she will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) after my death.

B.

A partial survivor annuity for my current spouse equal to 25% of my annuity.

C.

An insurable interest survivor annuity for my current spouse, but no regular survivor annuity for my current spouse. (I have completed Section F,
Box 4, on my RI 92-19, naming my current spouse.)

D.

A maximum survivor annuity for my former spouse ________________________________________________.

E.

A partial survivor annuity for my former spouse ___________________________________________________ equal to 25% of my annuity.

F.

A partial survivor annuity for my former spouse ___________________________________________________ equal to 25% of my annuity.

(name of former spouse)
(name of former spouse)
(name of former spouse)

Part 2 - To Be Completed By Current Spouse of Applicant
I freely consent to the survivor annuity election described in Part 1. I understand that my consent is final (not revocable).

Name (type or print)

Signature (do not print)

Date (mm/dd/yyyy)

Part 3 - To Be Completed By a Notary Public or Other Person Authorized to Administer Oaths
I certify that the person named in Part 2 presented identification (or was known to me), gave consent, signed or marked this form, and acknowledges that the consent was freely
given in my presence on this the __________________________ day of ______________________________________, ____________ at
(month)
(year)
____________________________________________________________________________________________.
(city, state)
Signature (do not print)

Seal

Expiration date of Commission, if Notary Public (mm/dd/yyyy)

General Information
Public Law 99-335 requires that a person who is married at the time his or her retirement annuity begins must elect to provide a full survivor annuity for a current spouse, unless the current spouse consents
to some other election by signing this form.
A court order which requires an annuitant to provide a survivor annuity for a former spouse is not an election and spousal consent is not required. In other words, such a court order does not require a
current spouse to waive the right to a survivor annuity. The retiring employee can still elect to provide a survivor annuity for the current spouse even though the Office of Personnel Management (OPM)
must honor the terms of the court order before it can honor the election for the current spouse. The current spouse may, therefore, receive a smaller annuity than elected, or none at all, unless the former
spouse loses eligibility for the court-ordered survivor annuity (through the terms of the court order, remarriage before age 55, or death).

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. Code Chapters 84, which, provides for both immediate and deferred retirement benefits, depending on the individual’s age and total service at separation.
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 determine whether the applicant is eligible for a deferred or postponed annuity and to compute the amount of the 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 noncompliance of the provisions of title 5, U.S.C, Chapter 84. Additionally, the award of benefits
could be delayed. Individuals who do not provide this information can also request changes via telephone or letter, as well as using RI 92-19. The information collected can only be obtained from the
respondents.

Public Burden Statement
We estimate that this form takes an average of 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
(3206-0190), Washington, D.C. 20415-0001. The OMB number, 3206-0190, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

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RI 92-19
Revised October 2022

Schedule B - For Applicants with Immediate MRA+10 Eligibility
(who may choose to postpone)
To be completed only by applicants who were eligible for an immediate MRA+10 annuity based on having reached the Minimum
Retirement Age and having at least 10 years of creditable service at separation. Read instructions carefully to determine if you
should complete this schedule.

Part 1 - Identifying Information
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

Part 2 - Commencing Date
Read the instructions carefully and
elect when you want your benefits to begin.

I want my benefit to begin accruing (mm/dd/yyyy)

Part 3 - Health Benefits Coverage
1.

When you separated from service, were you enrolled (or covered as a family member) in the Federal Employees Health Benefits Program?

No, go to Part 4.

Yes, complete 1a - 1c.
1a. What plan were you enrolled in when you separated (if known)?
1b. Do you want information on reenrolling with the Federal
Employees Health Benefits Program?

Plan Name

Yes
No

Enrollment Code
1c. Do you have a copy of your SF 2810
terminating your enrollment?

Yes, attach copy.
No

Part 4 - Life Insurance Coverages
1.

When you separated from service, were you enrolled in the Federal Employees' Group Life Insurance Program?

No, go to Part 5.

Yes, complete items 1a - 1d.
1a. What coverage(s) did you have when you separated?

Basic
Option A - Standard

Option B - Additional __________# of multiples (if known)
Option C - Family __________# of multiples (if known)

1c. Did you convert your coverage(s) to a private plan?

Yes

1b. Do you want information on starting
your coverage(s) again?

Yes

No

1d. Do you have a copy of your SF 2821 terminating your coverage(s)?

No

Yes, attach copy.

No

Part 5 - Federal Dental and Vision Program Coverage
1.

When you separated from service, were you enrolled in the Federal Dental and Vision Program (FEDVIP)?

No, go to Part 6.

Yes, complete items 1a - 1b.
1a. What plan were you enrolled in when you separated (if known)?

Plan Name

1b. Do you want information on reenrolling with the Federal Dental and Vision Program?

No

Yes

Part 6 - Long Term Care Insurance Coverage
1.

Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?

Yes. Your coverage will continue. If you want your premium
payments deducted from your annuity, call the FLTCIP
administrator, Long Term Care Partners, at 1-800-582-3337.

No. If you are not currently enrolled in the Federal Long Term Care
Insurance Program, you, your spouse, and your adult children may
apply for coverage provided you are eligible for a deferred or
postponed annuity. You may request an application by contacting
Long Term Care Partners, at 1-800-582-3337.

Part 7 - Applicant's Signature
Signature

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CSRS/FERS Handbook

RI 92-19
Revised October 2022

Schedule C - For Applicants with Deferred MRA+10 Eligibility
(who may choose to postpone)
To be completed only by applicants eligible for a deferred (non-immediate) annuity based on a separation from FERS covered
Federal service before attaining the Minimum Retirement Age and after performing at least 10 years of creditable service. Read the
instructions carefully to determine if you should complete this Schedule.

Part 1 - Identifying Information
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

Part 2 - Commencing Date
Read the instructions carefully and
elect when you want your benefits to begin.

I want my benefit to begin accruing (mm/dd/yyyy)

Part 3 - Long Term Care Insurance Coverage
1.

Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?

Yes. Your coverage will continue. If you want your premium
payments deducted from your annuity, call the FLTCIP
administrator, Long Term Care Partners, at 1-800-582-3337.

No. If you are not currently enrolled in the Federal Long Term Care
Insurance Program, you, your spouse, and your adult children may
apply for coverage provided you are eligible for a deferred or
postponed annuity. You may request an application by contacting
Long Term Care Partners, at 1-800-582-3337.

Part 4 - Applicant's Signature
Signature

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Date (mm/dd/yyyy)

CSRS/FERS Handbook

RI 92-19
Revised October 2022