ROA Privacy Act Statement

Generic Privacy Act Statement for 3206-0211

Pursuant to 5 U.S.C.§ 552a(e)(3), this Privacy Act Statement serves to inform you why OPM is requesting the information on this form.

Authority: OPM’s authorization to collect the information requested is Chapter 83, Title 5, U.S. Code (Sections: 8334, 8341, & 8342) and Chapter 84, Title 5, U.S. Code (Section 8411). OPM’s authorization to collect your Social Security number is Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008).

Purpose: The information you furnish will be used to identify records properly associated with
your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, to maintain a uniquely identifiable claim file, and to determine your eligibility to make deposits or redeposits to the  Civil Service Retirement and Disability Fund.

Routine Uses: The information requested on this form may be shared externally as a "routine use" to other Federal agencies and third-parties when it is necessary to process your application for benefits. 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 determination or continuation of benefits under this program, 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, if you fail to provide this information, it may result in a delay or prevent action on your application or render OPM unable to determine your eligibility to make deposits or redeposits for the Civil Service Retirement and Disability Fund.