Form OPM 1496A_Revised OPM 1496A_Revised You May Be Eligible for Deferred Retirement

Application for Deferred Retirement (Separations on or after October 1, 1956); OPM 1496A

OPM1496A_2023_01_Revised

Application for Deferred Retirement (Separations on or after October 1, 1956)

OMB: 3206-0121

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OMB Approval 3206-0121

United States
Office of Personnel Management
Retirement Operations Center
Boyers PA 16017
Date of birth (mm/dd/yyyy)
Date of separation giving eligibility (mm/dd/yyyy)
Commencing date of annuity (mm/dd/yyyy)

You May Be Eligible For Deferred Retirement
Records on file with the Office of Personnel Management (OPM) indicate that you may be eligible for a deferred annuity beginning on the
"commencing date" shown above. To apply for your annuity, complete the enclosed Application for Deferred Retirement and return it to OPM.
See the enclosed information.
Your annuity will be computed under the law in effect on the date of the separation on which your eligibility for annuity is based, using your
service listed below (unless we can verify additional service). If you have additional Federal service, list it in Section D of the enclosed
application and send us copies of any documents you may have to support your claim to that service.
A decision on your eligibility for an annuity and the amount of service to your credit will be made after we receive your application.

Department or Agency and Location

Beginning Date
(mm/dd/yyyy)

Ending Date
(mm/dd/yyyy)

Civil Service Retirement Deductions were:
Withheld

Not Withheld

Refunded

Remarks:

Keep the instructions (pages 1 thru 9) for your files.
Return this letter with your completed application in the
enclosed envelope or address them to:
Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045

Retirement Operations
Prior editions are not usable.

OPM 1496A
Revised January 2023

Application For Deferred Retirement
Civil Service Retirement System (CSRS)
(Separations on or after October 1, 1956)

Introduction
This package is for your use if you are a separated Federal employee
who wants to apply for deferred annuity based on a separation from
service covered by the Civil Service Retirement System (CSRS) on
or after October 1, 1956. This package does not include any
information on the provisions of the Federal Employees Retirement
System (FERS) Act of 1986.
Review all information carefully before you complete the
application. Special information which applies only to certain
separated Members of Congress and Congressional employees has
not been included. Keep the information sections of this package for
future reference.
Eligibility For Deferred Annuity
You are eligible for a deferred annuity if:
1.

You had at least 5 years of creditable civilian Federal service
at the time of your final separation from a position subject to
CSRS.

Item 7:

Provide your email address.

Item 8:

Indicate your citizenship.

Section B - Marital Information
Item 1:
Indicate whether or not you are married now. If you are
married, also complete Items 1a-1f with information
about your current marriage. Attach a copy of your
marriage certificate. Information about your marital
status and your spouse is necessary to ensure that you get
the survivor election that you want and to which you are
entitled by law. Attach a copy of your marriage
certificate.
Item 1a:

Enter your spouse's name.

Item 1b:

Enter your spouse's date of birth (mm/dd/yyyy).

Item 1c:

Furnish your spouse's Social Security Number.

Item 1d:

Enter the place of your marriage (town or city and state).

Item 1e:

Enter the date of your marriage (mm/dd/yyyy).

You were covered by CSRS for at least 1 year out of the last
2 years preceding the final separation on which entitlement is
based.

Item 1f:

If you were married by a clergyman or justice of the
peace, check that box. If not, check the box marked
"other" and explain how, or by whom, you were married.

You have not drawn a refund of retirement deductions covering
your final period of service.

Item 2:

Indicate whether you have a living former spouse whose
marriage to you ended by divorce, or annulment on or
after May 7, 1985, and to whom a court order gives a
survivor annuity. If you answer "yes," you must submit
a certified copy of the court order and any attachments
or amendments.

If your final period of service does not meet the "one out of two"
requirement, it will be eliminated from consideration. Retirement
deductions withheld during the period will be refunded. If possible,
entitlement will be based on a previous separation. A deferred
annuity commences on your 62nd birthday, no matter when you
apply for it. If you die before attaining age 62, or after age 62, but
before applying for annuity, the only benefit payable will be your
lump-sum credit in the retirement fund; and a monthly survivor
annuity will not be available.
Instructions For Completing Application For Deferred
Annuity
Section A - Identifying Information
Item 1: Type or print your name clearly.
Item 2: List other names under which you have been employed
in the Federal government (such as maiden name).
This will make it possible for us to locate and identify
records maintained under such names.
Item 3: Enter your Social Security Number. The U.S. Department
of Treasury requires us to report, by Social Security
Number, the amount paid to each annuitant.
Item 4: Enter the address to which correspondence should be
mailed. (Refer to page 6 for information about Direct
Deposit.)

Section C - Annuity Election
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.
The marriage duration requirement does not apply if your death is
accidental (as defined under the retirement regulations) or your
surviving spouse is a parent of your child.
Box 1: Spouse Survivor Benefit
If you initial either Box 1A or Box 1B, your spouse will receive a
survivor annuity upon your death. The amount of this survivor
annuity and the amount of the reduction in your annuity to provide
this benefit depend on the box you initial. For a full discussion of
the effect of court orders, see Important Information About Annuity
Election on page 2.
Box 1A: Maximum Survivor Benefit
If you initial Box 1A, you are electing the maximum survivor
benefit.
Final Separation on or after October 11, 1962
If you initial Box 1A, your spouse's survivor annuity upon your
death will be 55% of ALL of your annuity. Your annuity will be
reduced by 2-1/2% of the first $3,600 and 10% of the remainder
of your annual annuity to provide this benefit upon your death.

Item 5: Give a telephone number where you can be reached in
case more information is needed.
Item 6: Give your date of birth, showing the month, then the day,
then the year. Your retirement records are filed by your
name and date of birth. If your date of birth is not correct
on the letter with this package, send proof of your date of
birth (such as your birth certificate) with your application.
OPM 1496A
Revised January 2023
Page 1

Final Separation before October 11, 1962
If you initial Box 1A, your spouse's survivor annuity upon your
death will be 50% of ALL your annuity. Your annuity will be
reduced by 2-1/2% of the first $2,400 and 10% of the remainder of
your annual annuity to provide this benefit.
Box 1B: Less than Maximum Survivor Benefit
If you initial Box 1B, you must complete and attach OPM Form
1496A, Schedule B, Spouse's Consent to Survivor Election. The law
requires consent of the spouse if a married person elects less than the
maximum survivor benefits. (See Important Information About
Annuity Election below for exceptions to the consent requirements.)
Final Separation on or after October 11, 1962
If you initial Box 1B, your spouse's survivor annuity upon your
death will be 55% of the annual amount you specify in the blank
space (which must be less than the full amount of your annual
annuity). Your annuity will be reduced by 2-1/2% of the first
$3,600 and 10% of any additional amount you specify.
Final Separation before October 11, 1962
If you initial Box 1B, your spouse's survivor annuity upon your
death will be 50% of the annual amount you specify in the blank
space (which must be less than the full amount of your annual
annuity). Your annuity will be reduced by 2-1/2% of the first
$2,400 and 10% of any additional amount you specify.
Box 2: No Survivor Benefit
If you are married and initial Box 2, you must also complete and
attach to your application OPM Form 1496A, Schedule B, Spouse's
Consent to Survivor Election. The law requires that your spouse
consent if you elect less than the maximum or no survivor annuity.
(See Important Information About Annuity Election below for
exceptions to the consent requirement.)
If you initial Box 2, you will receive an annuity payable only during
your lifetime, without monthly survivor annuity for your spouse.
All applicants, married and unmarried, may choose this type of
annuity. However, you should review carefully all information
provided here before making your election.
Box 3: Former Spouse or Combination Current/Former Spouse
Benefit
You are not eligible to elect a survivor annuity for a former spouse
if the dates of your 62nd birthday and divorce, or annulment
occurred before May 7, 1985.
If you initial Box 3, you must use OPM Form 1496A, Schedule A,
Election of Former Spouse Survivor Annuity or Combination
Current/Former Spouse Annuity, to make your election. Read the
information at the bottom of Schedule A. You are not permitted to
elect a benefit for a former spouse who remarried before reaching
age 55. Complete OPM Form 1496A, Schedule B, Spouse's Consent
to Survivor Election, if you are married and initial Box 3. (See
Important Information About Annuity Election below for exceptions
to the consent requirements.)
If you initial Box 3, after your death, the person(s) you elect will
receive the percentage of your annuity you select. Your annuity will
be reduced by 2-1/2% of the first $3,600 and 10% of the remainder
as you specify.

Box 4: Insurable Interest Survivor Benefit
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. Insurable interest exists if the person named (such as a
close relative) may reasonably expect to derive financial benefit
from your continued life. Enter the requested information about the
person selected on your application.
You must submit medical evidence that you are in good health.
If you initial Box 4, we will send you a notice describing the
medical evidence you must submit.
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
table below. The survivor's rate will be 50% of your reduced
annuity, if final separation was before October 11, 1962; and 55% if
final separation was on or after October 11, 1962.
Age of 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 10 years younger

15%

10 but less than 15 years younger

20%

15 but less than 20 years younger

25%

20 but less than 25 years younger

30%

25 but less than 30 years younger

35%

30 or more years younger

40%

If you were 62 on or after May 7, 1985, you may elect an insurable
interest survivor annuity for another person in addition to a regular
survivor annuity for a current or former spouse. However, if you
elect an insurable interest for your current spouse, you must both
jointly waive the current spouse annuity. If you elect the insurable
interest annuity for a current spouse because a court order awards
(or you have elected) the regular survivor annuity to a former
spouse, the insurable interest election for your current spouse can
be converted to a current spouse annuity if the former spouse loses
entitlement to the regular survivor annuity through death or
remarriage prior to reaching age 55. The 9-month marriage duration
requirement does not apply to insurable interest annuities.
Important Information About Annuity Election
If you are married at retirement and do not indicate your annuity
election, you will receive an annuity reduced to provide the
maximum survivor benefit (as though you had initialed Box 1A).
If you are married at retirement and elect less than the maximum
survivor benefits for your spouse (that is, you choose 1B, 2, 3, or 4,
described above), the law requires that your spouse consent on OPM
Form 1496A, Schedule B, Spouse's Consent to Survivor Election,
unless the consent requirement does not apply to you. Your
application will be processed on the basis of maximum survivor
benefits if this form is required but not attached.

OPM 1496A
Revised January 2023
Page 2

Notice to Applicants Who Married After Age 62
Since you were not married to your current spouse at age 62 (the
commencing date of your deferred annuity), you do not need your
spouse's consent to your annuity election in Section C. Please refer
to Annuity Election Changes After Retirement, item 6,
for detailed information.
Waiver of Spousal Consent Requirement
The spousal consent requirement may be waived if you show that
your spouse's whereabouts cannot be determined. A request for
waiver on this basis must be made in writing and accompanied by:

► A judicial determination that your spouse's whereabouts
cannot be determined; or

► Affidavits by you and two other persons, at least one of

whom is not related to you, attesting to the inability to
locate the current spouse and stating the efforts made to
locate the spouse. You must also give documentary
evidence, such as tax returns filed separately or
newspaper stories about the spouse's disappearance.

The spouse's consent requirement may also be waived if you present
a judicial determination regarding the current spouse that would
warrant waiver of the consent requirement based on exceptional
circumstances. (Illness or injury of the retiree is not justification
for waiving the spousal consent requirement.)
Court-Ordered Former Spouse Annuities
OPM must honor a court order/divorce decree on or after May 7,
1985, that gives (awards or requires you to provide) a survivor
annuity to a former spouse. OPM cannot honor court-order
modifications issued after retirement involving a former spouse
survivor annuity. Your annuity will be reduced to provide the
survivor annuity for the former spouse. However, a former spouse
cannot receive a survivor annuity by a court order unless:

You may elect to provide a survivor annuity for more than one
former spouse. If you are married, you may elect a survivor
annuity for your current spouse as well as a survivor annuity for
one or more former spouses. However, the total of the survivor
annuities may not exceed 55%* of your unreduced annuity.

To elect a reduced annuity to provide a survivor annuity for a
former spouse or a combination of survivor annuities for a
current and former spouse(s), complete and attach OPM Form
1496A, Schedule A, Election of Former Spouse Survivor
Annuity or Combination Current/Former Spouse Annuity.

Electing a Survivor Annuity for a Current Spouse When a
Court Order Gives a Survivor Annuity to a Former Spouse
1. If a court order has given a survivor annuity to a former spouse,
you must make your election concerning a survivor annuity for
your current spouse as if there were no court-ordered former
spouse annuity. By electing the maximum survivor benefits for
your current spouse at retirement, you can protect your
spouse's rights in case your former spouse loses entitlement in
the future (because of remarriage before age 55, under the
terms of the court order, or death). You can do this because the
CSRS must honor the terms of the court order and you are not
required to ELECT a survivor annuity for the former spouse.
(Note: The election you make now regarding a survivor
annuity for your current spouse cannot be changed except as
explained in the section titled Annuity Election Changes After
Retirement.) The following paragraphs explain in more detail
how your election at the time of retirement can affect your
current spouse's future rights if the court has given a survivor
annuity to a former spouse.
2.

If a court order gives a survivor annuity to a former spouse,
your annuity will be reduced to provide it. If you elect a full
or partial survivor annuity for your current spouse (or another
former spouse), your annuity will be reduced no more than it
would be to provide a survivor annuity equal to 55%* of your
unreduced annuity.

If you die before your current and former spouse, the total
amount of the survivor annuities paid cannot exceed 55%* of
your annuity, and the CSRS must honor the terms of the court
order before it can honor your election. The former spouse
having the court-ordered survivor benefit would receive an
annuity according to the terms of the court order.

If a court order gives the maximum survivor annuity to the
former spouse, your current spouse would receive no survivor
annuity until the former spouse loses entitlement. Then, your
current spouse would receive a survivor annuity according to
your election.

If the court order gives less than the maximum survivor annuity
to the former spouse, your current spouse would receive an
annuity no greater than the difference between the court-ordered
survivor annuity and 55%* of your annuity. However, if the
former spouse loses entitlement to the survivor annuity (through
remarriage before age 55, under the terms of the court order, or
death), your current spouse's survivor annuity would be
increased to the amount you elected.

1. Your spouse was married to you for at least 9 months;
2. You have at least 18 months of service subject to retirement
deductions;
3. Your spouse has not remarried before reaching age 55; and
4. The marriage ended on or after May 7, 1985.
If you are married and a court order has awarded a survivor annuity
to your former spouse, see the following section Electing a Survivor
Annuity for a Current Spouse When a Court Order Gives a Survivor
Annuity to a Former Spouse. This explains how you can protect your
current spouse's future survivor annuity rights.
Electing a Survivor Annuity For a Former Spouse or a
Combination of Survivor Annuities for Current and Former
Spouses
If your marriage ended on or after May 7, 1985, you may elect a
reduced annuity to provide a maximum (55%* of your unreduced
annuity) or less-than-maximum survivor annuity for a former spouse
(or spouses).
1.

To make a former spouse annuity election, you must have been
married to the person for a total of at least 9 months and you
must have at least 18 months of service that was subject to
retirement deductions. A former spouse who marries again
before reaching age 55 is not eligible for a former spouse
survivor annuity.

* The maximum is 50% if you separated from Federal service before October 11, 1962.

OPM 1496A
Revised January 2023
Page 3

For example, if there is a court-ordered former spouse survivor
annuity that equals 40% of your annuity, you elect the maximum
survivor annuity for your current spouse, and you die before the
former spouse's entitlement to a survivor annuity ends, the former
spouse would receive a survivor annuity equal to 40% of your
annuity and your current spouse would receive a survivor annuity
equal to 15% of your annuity. However, if the former spouse later
loses entitlement to the survivor annuity (through remarriage before
age 55, under the terms of the court order, or death), your current
spouse would then receive a survivor annuity equal to 55% of your
annuity.
Electing an Insurable Interest Annuity for a Current Spouse
See the discussion on page 2 of these instructions for the definition
of Insurable Interest.
1.

If a former spouse's court-ordered survivor annuity will prevent
your current spouse from receiving a survivor annuity that is
sufficient to meet their anticipated needs, you may want to elect
an insurable interest annuity for your current spouse.

Annuity Election Changes After Retire
1. Subject to the consent requirement, you may name a new
survivor or change your election if, not later than 30 days after
the date of your first regular monthly payment, you file a new
election in writing. If the person you named to receive a
survivor annuity dies, or your current marriage ends through
death, divorce, or annulment, you must inform OPM
immediately. Your first regular monthly payment is the first
annuity payable on a recurring basis after OPM has initially
determined the regular rate of annuity payable under CSRS
and has paid the annuity accrued since you reached age 62.
2.

When the 30-day period following the date of your first regular
monthly payment has passed, you cannot change your election,
except under the circumstances explained in the following
paragraphs.

You may change your decision not to provide a survivor
annuity for your spouse at retirement. Or, you may increase the
survivor annuity amount you elected for your spouse at
retirement if you request the change in writing no later than
eighteen (18) months after the commencing date of your
annuity, and if you pay a deposit representing the difference
between the reduction for your new survivor election and the
original survivor election, plus a charge of $245.00 for each
thousand-dollar change in the designated survivor base.
(Interest on the deposit must also be paid.) Such an election
would cancel any joint waivers made at retirement. However,
the total survivor annuity(ies) provided for former spouses (by
court order or election) and the current spouse cannot exceed
55% of your annuity. You may not change your election to
provide a lesser survivor benefit for your spouse, except as
discussed in item 1 above.

The reduction in your annuity to provide a survivor annuity for
your current spouse stops if your marriage ends because of
death, divorce, or annulment. However, you may elect, within
two (2) years after the marriage ends, to continue the reduction
to provide a former spouse survivor annuity for that person,
subject to the restrictions in paragraph 10. If you marry
someone else before you make this election, your new spouse
must consent to your election.

The reduction in your annuity to provide a survivor annuity for
a former spouse ends: (1) when the former spouse dies,
(2) when the former spouse remarries before reaching age 55,
or (3) under the terms of the court order that required you to
provide the survivor annuity for the former spouse when you
retired. (Modifications of the court order issued after you retire
do not affect the former spouse annuity.) If you and your former
spouse were married for 30 years or longer, the reduction does
not end. However, if at retirement you had elected a survivor
annuity for your current spouse (or another former spouse),
the reduction will be continued to provide the survivor annuity
for that person. If you have not previously made an election
regarding a current spouse whom you married after retirement
(or if your election regarding a current spouse at retirement
was based on a waiver of spousal consent), you may, within
2 years after the former spouse loses the right to a survivor
annuity, elect a reduced annuity to provide a survivor annuity
for that current spouse. This election is subject to the
restrictions given in paragraph 10.

If you elect an insurable interest survivor annuity for your
current spouse, you and your current spouse must jointly waive
the regular survivor annuity. To accomplish this:
a.

initial box 1B in Section C of the OPM Form 1496A, and
write "none" in the space following that box (i.e., election
to provide no regular survivor annuity);

complete Section C, item 4 naming your current spouse
(i.e., election to provide insurable interest benefit);

complete Part 1, item b of OPM Form 1496A, Schedule B;

have Parts 2 and 3 of Schedule B completed (i.e., spouse
consent to insurable interest benefit in lieu of regular
survivor annuity).

If you elect an insurable interest survivor annuity for your
current spouse and your former spouse loses entitlement before
you die, you may request that the reduction in your annuity
to provide the insurable interest annuity be converted to the
regular spouse survivor annuity; this would result in a larger
annuity. (See Annuity Election Changes After Retirement.)
Your current spouse would then be entitled to the regular
survivor annuity. In addition, if your former spouse loses
entitlement after you die, your spouse can ask OPM to
substitute the regular survivor annuity for the insurable interest
survivor annuity.
If, for any reason, OPM cannot allow your insurable interest,
election for your current spouse, your current spouse will be
considered elected for a maximum regular survivor annuity,
unless your current spouse signs another form consenting
to less than a maximum regular survivor annuity, or OPM
approves a waiver of consent.

* The maximum is 50% if you separated from Federal service before October 11, 1962.

OPM 1496A
Revised January 2023
Page 4

If you were not married at retirement, you may elect, within 2
years after a post-retirement marriage, a reduced annuity to
provide a maximum, or less-than-the-maximum survivor
annuity for your spouse, subject to the restrictions given in
paragraph 10. Your annuity will be reduced no earlier than nine
(9) months after the date of your marriage.

If you were married at retirement, that marriage ends, and you
marry again, you may elect, within 2 years after the marriage,
a reduced annuity to provide a survivor annuity for your new
spouse, subject to the restrictions given in paragraph 10. Please
note that the pre-divorce survivor annuity election automatically
terminates upon divorce. You must make a new election within
2 years after the divorce to provide a survivor annuity for a
former spouse. Continuing a survivor reduction, by itself, is not
a former spouse survivor election. (However, if you remarry the
same person you were married to at retirement and that person
had previously consented to your election of no survivor
annuity, you may not elect to provide a survivor annuity for that
person when you remarry.) Your annuity will be reduced no
earlier than 9 months after the date of your marriage.

If, at retirement, you received (by election or court order) a
reduced annuity to provide a survivor annuity for a former
spouse and you elected to provide an insurable interest survivor
annuity for your current spouse, you may change the insurable
interest election to a regular current spouse survivor annuity
within 2 years after your former spouse loses entitlement
(because of remarriage before age 55, the terms of the court
order, or death), subject to restrictions a and b given in
paragraph 10.
The reduction in your annuity to provide an insurable interest
annuity ends if the person you named to receive the insurable
interest annuity dies, or when the person you named is your
current spouse, and you change your election as explained in
paragraph 8. The reduction also ends if, after you retire, you
marry the insurable interest beneficiary and elect to provide a
regular survivor annuity for that person. If you marry someone
other than the insurable interest beneficiary after you retire, and
elect to provide a regular survivor annuity for your new spouse,
you may elect to cancel the insurable interest reduction.

10. Post-retirement survivor elections are subject to the following
restrictions:
a.

They cannot be honored to the extent that they conflict
with the terms of a court order that requires you to
provide a survivor annuity for a former spouse;

They cannot be honored if they cause the combined
current and former spouse survivor annuities to exceed
55%* of your unreduced annuity; and

If, during any period after you retire, your annuity was
not reduced to provide a current or former spouse
survivor annuity, you must pay into the retirement fund
an amount equal to the amount your annuity would
have been reduced during that period, plus 6% annual
interest.

11. Insurable interest elections are not available after retirement.

* The maximum is 50% if you separated from Federal service before October 11, 1962.

Section D - Federal Service
The letter attached to this package includes a list of your Federal and
Postal service presently included in your retirement records. If you
have performed any additional civilian Federal or Postal service,
before or after the date of final separation, list it in the spaces
provided. Attach additional sheets of paper if more space is needed.
Attach a copy of any available documentation you may have to
verify the additional service claimed. Documentation which may be
useful in verifying service includes notices of appointment,
separation or salary change. OPM will attempt to locate official
records to verify your claim, even if you cannot supply
documentation. If we are unable to do so, we will let you know.
Information you give will help us to assure proper credit for all your
service.
Federal service is service as an employee of the United States
Government. Generally, to be considered an employee of the United
States Government for civil service retirement purposes, a person
must be:
a.

engaged in the performance of Federal functions under
the authority of an act of Congress or an Executive
Order,

appointed in the civil service by a Federal officer, and

under the supervision and direction of a Federal officer.

Section E - Military Service
Military service can be added to your civilian Federal service under the
circumstances outlined below:
Item 1: If you have performed active duty that terminated under
honorable conditions in the armed services or other
uniformed services of the United States, enter, for each
period of active duty, (a) the branch of service (Army, Navy,
etc.), (b) your serial number for that period of service, (c)
the beginning and ending dates of active duty, (d) your last
grade or rank during that period of service, and (e) your
organization (company, division, etc.) at discharge.
If available, attach a copy of your discharge certificate or
other documentation of the active military service.
Active military service, generally rendered on a full-time basis with
military pay and allowances, includes the following:

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

Cadet at the U.S. Military Academy, U.S. Air Force
Academy, U.S. Coast Guard Academy, or Midshipman
at the U.S. 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.

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 title10) if the National Guard duty
interrupts creditable civilian service under subchapter III
of chapter 83 of title 5, and is followed by reemployment
in accordance with Chapter 43 of title 38 that occurs on or
after August 1, 1990.
OPM 1496A
Revised January 2023
Page 5

Merchant Marine service is not creditable as military service.
Information about your active duty military service is needed so that
we can compare your claim with other records and request
verification of all claimed military service. This ensures that you are
credited with the correct amount of active military service.
Deposit for Military Service
Persons who performed active duty military service after December
31, 1956, may have paid a deposit to avoid an annuity reduction.
Read the following discussion to determine which category
describes your service. The deposit is 7% of the military basic pay
you received, plus interest at a variable rate determined each year by
the U.S. Department of Treasury. Interest is charged if the deposit is
paid after October 1, 1986, or three years after you were first
employed in a civilian position subject to CSRS coverage,
whichever is later. If you did not pay your deposit while you were
still Federally employed, you cannot pay it now, unless your final
separation occurred as stated in 1b below.
1. If you were first employed in a civilian position subject to
CSRS coverage before October 1, 1982, and
a.

If you were separated from the Federal service before
October 1, 1982, we will allow credit for military service
after 1956 until you are eligible for social security. Then,
we will offset the amount of your civil service benefit
that is attributable to your post-1956 military service by
any amount of social security benefit that is also
attributable to that service. The law does not provide
for you to pay a deposit. If you are able to send us
information and documentation concerning your
eligibility for social security benefits, it may help us
to process your application more quickly.
If you separated from the Federal service on or after
October 1, 1982, you had the option of paying a deposit
for post-1956 military service in order to avoid any
reduction that would otherwise take effect when you
became eligible for social security benefits. An exception
to the rule that the deposit must be paid while the
individual is still employed exists for individuals whose
final separation from Federal employment occurred
between October 1, 1982, and October 1, 1983. These
persons may pay the deposit directly to OPM.

If you were first employed in a civilian position subject to
CSRS coverage on or after October 1, 1982, you must have paid
the deposit for post-1956 military service in order to receive
credit for that service for retirement purposes. In other words,
unless you paid the deposit, we will not allow credit for
post-1956 military service at the time your annuity commences,
regardless of whether you are, or will become eligible for social
security benefits.

Item 2: Indicate whether or not you are receiving or have applied
for military retired pay. (Military retired pay includes
disability pay.)
If you are receiving military retired pay, your military service cannot
be used for civil service retirement purposes, unless such retired pay
was awarded on account of a service-connected disability incurred
in combat or caused by an instrumentality of war in the line of duty
during a war period, or was awarded under Chapter 1223, title 10,
U.S. Code, Sections 12731 through 12739, formerly Chapter 67, title
10 (reserve retired pay at age 60 based on 20 years of active and
reserve service). If you are receiving military retired pay and wish
to combine your military and civilian service to compute your civil
service annuity, you must waive your military retired pay.

In order to waive military retired pay you should 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. Preferably, this should be done at
least 60 days before the commencing date of your civil service
annuity (your 62nd birthday). Your letter might say, "I, (full name,
military serial number, and Social Security Number), hereby waive
my military retired pay for civil service retirement purposes,
effective close of business (the day before annuity commences)."
If you wish, add "I authorize the Office of Personnel Management
to withhold from my civil service 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 active duty military service for civil service retirement
purposes, attach a copy of your request for waiver and of any reply
you have received.
Section F - Other Claims Information
Item 1: Indicate which in 1a and the applicable claim numbers in
1b. This helps to ensure that all of your records are
located and that proper credit is given for your service,
and for any deposit, redeposit, or voluntary contribution
payments you have made.
Item 2: Indicate whether or not you have ever been employed
under another retirement system for Federal or District
of Columbia employees. If your answer is "yes," fill in
the name of that retirement system in 2a and the dates of
service in 2b. This helps to ensure proper consideration is
given to all of your service. The service you show here
cannot be used to compute your civil service annuity if
the other retirement system is paying you retirement
based on the service.
Item 3: If you have applied for, or received, workers'
compensation from the Office of Workers' Compensation
Programs (OWCP), U.S. Department of Labor, because
of a job-related illness or injury sustained during Federal
employment, check the "yes" box and furnish your claim
numbers and dates of benefits in 3a and 3b.
The information requested regarding benefits from the OWCP is
needed because the law prohibits payment of both civil service
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.
Section G - Direct Deposit/Direct Express
The U.S. Department of the Treasury pays all federal benefits
electronically. Your payments can be made by Direct Deposit to
your checking or savings account, or you need to arrange for a
Direct Express debit card provided by the U.S. Department of the
Treasury. To enroll in the Direct Deposit program, contact your
financial institution or OPM. To obtain a debit card, go to
www.godirect.gov. If your payments are not electronically deposited
to your account and you do not have a Direct Express card, you must
contact the U.S. Department of the Treasury at 1-800-333-1795 to
discuss your options. This does not apply if your permanent
payment address is outside the United States in a country not
accessible via Direct Deposit/Direct Express.

OPM 1496A
Revised January 2023
Page 6

Use Section G, item 3 to give OPM instructions regarding Federal
income tax withholding. If you would like tax withheld, please
include the Internal Revenue Service (IRS) Form W-4P,
Withholding Certificate for Periodic Pension or Annuity Payments
(2022 or later version).The form is available at IRS.gov. If you do
not provide a form or instructions, the IRS has instructed OPM to
withhold at the rate of single with zero adjustments.
After your application is processed, you will be able to instruct OPM
to withhold State income tax, provided your State participates in
OPM's State Tax Withholding Program.
Section H - Certification of Applicant
Be sure to sign (do not print) and date your application, after reviewing
the warning.
Filing Your Application
Send your completed application, and any attachments requested
in the instructions or the letter, to the Office of Personnel
Management, Civil Service Retirement System, Retirement
Operations Center, Boyers, Pennsylvania, 16017.
What Happens After You File Your Application
1. OPM will acknowledge receipt of your application and give you
a Retirement Reference Card showing the claim number
assigned to your application. The claim numbers begin with the
letters "CSA." This number is very important to you; you will
need to refer to it any time you contact us in connection with
your annuity.
2.

We will search our files for all records and previous claims
related to your Federal service and place these with your
application in your CSA claim file.

We will determine if any additional information is needed to
adjudicate your claim and obtain it. For example, we may need
to obtain official records of service claimed by you but not
recorded in our files, such as certification of your military
retired pay status, etc. We can obtain most of this information
from other Federal agencies. We will let you know if any
additional information is needed from you. Finally, we will
compute the amount of your annuity.

When we finish processing your application, we will send you
a booklet explaining your benefits and any monthly survivor
benefits. This booklet contains information you will need,
including how to contact OPM to make various changes (tax
withholding, address, change in marital status, etc.)

What To Do If Your Address Changes Before
Processing Is Completed
If your address changes, call us using the numbers on page 8 or
write us over your personal signature, giving your name, date of
birth, Social Security Number, and your new address. Remember
to refer to your claim number. If you write to us, report your new
address to:
U.S. Office of Personnel Management
Attn: Change of Address
P.O. Box 440, Boyers, PA 16017-0440
In addition, you should notify the U.S. Postal Service of your forwarding
address.

Cost-of-Living Increases
1. Limitation on amount of increase
An annuity may not be increased by a cost-of-living adjustment
to an amount that exceeds the greater of (a) the maximum pay
payable for a GS-15 thirty (30) days before the effective date of
the adjustment or (b) the final pay (or average pay, if higher) of
the retired employee, increased by the overall annual average
percentage adjustments (compounded) in General Schedule
rates of pay since the employee's retirement.
2.

Determination of amount of increase and effective
date
Cost-of-living increases are effective on December 1 and are
payable in the January annuity payment. They are determined
by the percentage increase in the average Consumer Price Index
for the "base quarter" of the year in which they are effective
over the "base quarter" of the preceding year. The "base
quarter" is July, August, and September. The first cost-of-living
increase you receive will be prorated to reflect the number of
months you are on the retirement rolls before the increase is
effective.

Amount of Annuity
OPM will compute your annuity. See Annuity Computation for
more information.
Length of Service
Add up the years, months, and days of all your periods of Federal
service, including creditable military service, before your final
separation from civilian service covered by the retirement act.
The total years and months constitute your length of service.
Any days left over, that don't make a full month, are dropped.
Average Pay
Final Separation from September 30, 1956, to October 19, 1969
Your "high-5" average pay, which is the highest average annual pay
produced by your basic pay rates during any 5 consecutive years of
service, each rate weighted by length of time it was in effect, is used
in the computation of your annuity. In most cases, the last 5 years of
service give the highest average pay, but any 5 consecutive years
may be used. Within-grade periodic pay increases are part of basic
pay, but additional pay such as overtime is not.
Final Separation from October 20, 1969, to the Present
Your "high-3" average pay, computed as described in the previous
paragraph but using 3 years instead of 5, is used in the computation
of your annuity if your final separation was on or after October 20,
1969.
Annuity Computation
The amount of your annuity is a percentage of your average pay.
The percentage is determined by a three-part formula based on your
length of creditable service. Credit is given for whole months only,
defined as 30 days. You earn:
1.50% per year for the first 5 years, or 7.50%, and
1.75% per year for the next five years, or 8.75%, and
2.00% per year for service over ten years.

OPM 1496A
Revised January 2023
Page 7

Thus, after ten years of service you have earned 16.25% [7.50%
+8.75%] of your average pay. After 8 years and 3 months of service
you have earned 13.19% of your average pay [7.50% + (1.75% X
3.25) = 13.19%]. To give another example, after 15 years and 6
months of service you have earned 27.25% of your average pay
[16.25% + (2% X 5.5) = 27.25%].
If your average pay is less than $5,000, you may substitute 1% of
your average pay plus $25 for the percentages in any or all parts of
the formula if it increases your basic annuity.
The result of the computation is your basic annuity, which must be
reduced for any or all of the applicable reasons described in the
following sections, to produce your yearly annuity rate. To find your
monthly payment amount, divide your yearly rate by 12 and round
down. Annuities based on final separations before October 20, 1969,
are increased by $20.00 per month.
Reduction for Refunded Service
Civilian service for which retirement deductions were withheld from
your salary and later refunded to you is called "refunded" service.
A "redeposit" is a payment to the retirement fund to cover a period
of refunded service. Generally, you do not have to make a deposit if
you do not wish to do so. However, this can affect the amount of
your monthly annuity.
If redeposit is not made for refunded service which ended on or
after March 1, 1991, you will receive no credit in the computation
of your annuity for the period of refunded service. This usually
results in a reduction in the amount of your annuity, or, in the event
of your death, your eligible spouse's annuity. The period of service
will be creditable for title and average salary purposes whether or
not a redeposit is made.
If redeposit is not made for refunded service which ended before
March 1, 1991, and if you separated from service on or after
October 28, 2009, you will receive credit in your annuity
computation for the period of refunded service. If you do not pay the
redeposit for this service, full credit for the refunded service will be
allowed in computing your annuity, but the annuity will be
permanently actuarially reduced based on your age and the amount
of redeposit, including interest, you owe at age 62. You can elect to
pay the redeposit and avoid the actuarial reduction.
If redeposit is not made for service which ended before October
1, 1990, and your annuity commences on or after December 2, 1990,
you will receive credit for the period of service covered by the
refund in your annuity computation. However, if you do not pay the
redeposit for this service, your annuity will be permanently,
actuarially reduced.

This reduction does not apply, and no deposit need be made for
military service performed before January 1, 1957. If you do not
make a deposit for civilian service performed on or after October 1,
1982, for which no retirement deductions were made, the service
cannot be used in computing the annuity. If you have such service,
you will be given an opportunity to pay the deposit with interest
before we complete our action on your application.
Reduction for Survivor Annuity
This reduction is explained under Instructions for Completing
Application, Section C, Annuity Election on page 1.
Unmarried children under 18, disabled children over 18, and student
children under age 22 may be eligible for survivor annuity after your
death. This eligibility does not depend on the type of annuity you
elect and does not reduce the amount of your annuity.
Additional Annuity
An employee who, in addition to the amounts withheld from salary,
has made voluntary contributions to the retirement fund will be paid,
in addition to the regular annuity, $8.40 for each $100.00 in their
voluntary contributions account. If an employee elects a voluntary
contributions survivor annuity, the additional annuity purchased will
be reduced based on the difference between the annuitant's age and
the survivor's age. The survivor's additional annuity is 50% of the
employee's additional reduced annuity. Note: The additional annuity
is not increased by cost-of-living adjustments.
If you have not already done so, you may request a refund of your
voluntary contributions. However, interest on refunded voluntary
contributions does not accrue after the date you separated from
your Federal employment.
Payment and Accrual of Annuity
All annuities are payable in monthly installments on the first
business day of the month following the one for which the annuity
has accrued. Monthly annuity rates are rounded down to the next
lower dollar. This provision also applies to annuities that were
redetermined and to cost-of-living adjustments.
If You Need Help To Complete This Application
Write to:
U.S. Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045

If redeposit is not made for service which ended on or after
October 1, 1990, any such period of service for which you have
been paid a refund of retirement deductions cannot be included in
your length of service unless you redeposit the refund.

You may call our Retirement Information Office toll-free at
1-888-767-6738 Monday through Friday from 7:40 a.m. to 5:00
p.m. EST. That office is closed on Federal holidays. Hearing
impaired users should utilize the Federal Relay Service by dialing
711 or their local communications provider to reach a
Communications Assistant.

We will send you information about the amount of redeposit and its
effects on your annuity and will give you an opportunity to pay the
redeposit.

We also provide retirement brochures, forms, and other
information on the Internet at www.opm.gov/retirement-services
and respond to email sent to [email protected].

Reduction for Non-Deduction Service
If you have creditable service performed before October 1, 1982,
during which no retirement deductions were made from salary and
for which deposit has not been made in the retirement fund, your
basic annuity will be reduced by 10% of the unpaid deposit. The
unpaid deposit consists of the amount which would have been
withheld as retirement deductions, plus interest.

OPM 1496A
Revised January 2023
Page 8

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 by Civil Service Retirement Law (5 USC 8338) and regulations (5 CFR 831.501) which require that OPM adjudicate and pay
deferred annuities. Purpose: OPM is requesting this information to determine whether the applicant is eligible for a deferred annuity and to compute the amount of the annuity.
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 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 determining your eligibility for refund, 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, OPM may be unable to process your application for retirement benefits.

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,
Retirement Services Publications Team (3206-0121), Washington, D.C. 20415-0001. The OMB Number, 3206-0121 is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.

OPM 1496A
Revised January 2023
Page 9

OMB Approval 3206-0121

Civil Service Retirement System

Application For Deferred Retirement

(For persons separated on or after October 1, 1956)
Please read the Instructions carefully before you complete this application.
Section A - Identifying Information

1. Name (last, first, middle)

2. List all other names used

3. Social Security Number

4. Address (number, street, city, state, ZIP code)

5. Telephone number (including area code)

6. Date of birth (mm/dd/yyyy)

7. Email address
8. Are you a citizen of the United States of America?

Yes

8a. Name of country of which you are a citizen

►

No - If "No," give

Section B - Marital Information

1. Are you married now? (A marriage exists until ended by death, divorce, or annulment.)

Yes (also complete items 1a - 1f below. Attach a copy of your marriage certificate)

1a. Spouse's name (last, first, middle)

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

1c. Spouse's Social Security Number

1d. Place of marriage (city, state)

1e. Date of marriage
(mm/dd/yyyy)

1f. Marriage performed by
Clergyman or Justice of the Peace
Other (explain):

Statement Regarding Former Spouses - All applicants must complete this statement if their annuities commence on or after May 7, 1985.
2. Do you have a living former spouse(s) whose marriage to you ended by divorce or annulment on or after May 7, 1985, and to whom a court order gives a survivor annuity?

Yes - Attach a certified copy of the court order(s) and any amendments.

Section C - Annuity 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 finally granted except as explained in the attached instructions. 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 OPM Form 1496A, Schedule B and attach it to this application.
Initials

Digital Initials

1. I choose a reduced annuity with survivor annuity for my spouse
equal to:

OR
Initials

50% of all my annuity
(Separation before 10/11/62)
B)

Digital Initials

I choose a self-only annuity.
(If you are married and elect this, complete and attach Schedule B.)

I choose a reduced annuity to provide a former spouse or combination
current/former spouse survivor annuity. The attached Schedule A gives
my election.
(If you are married and elect this, complete and attach Schedule B.)
I choose a reduced annuity with a survivor annuity for the person
named below who has an insurable interest in me.
(You may initial this box and also boxes 1 or 3 above.)

Name of person with insurable interest

Relationship to you

Initials
Digital Initials

55% of all my annuity
(Separation on or after 10/11/62)

50% of
(Separation before 10/11/62)

* a year

50% of
(Separation before 10/11/62)

* a year

All retiring former employees may
choose this type of annuity.

Initials
Digital Initials

You must be healthy and willing to undergo a physical
examination if you choose this type of annuity. Note: This
election is not included in determining the 55% maximum for
the combined benefit elected for a spouse and former spouse in
box 5.

Date of birth (mm/dd/yyyy)

Social Security Number

* This amount must be less than your yearly annuity.

U.S. Office of Personnel Management
Previous editions are usable

OPM 1496A
Revised January 2023

Section D - Federal Service

List below any Federal (or Postal) service you have performed that is NOT included in the list of your service on the form notifying you of your eligibility for deferred
retirement. Attach any documentation you may have to prove your claim to additional service.
Dept. or agency, including bureau or division

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

Location (city and state)

Section E - Military Service

1. If you have performed active, honorable service in the Armed Services or other uniformed services of the United States (see instructions for definition), complete items
1a-1e below and attach a copy of your discharge certificate or other certificate of active military service (if available).

1a.

Branch of service

1b.

Serial number

1c.

Dates of service
From (mm/dd/yyyy)

To (mm/dd/yyyy)

1d.

Last grade or rank

1e.

Organization at discharge
(Div., Co., etc.)

2. If you are receiving or have applied for military retired pay (including disability retired pay), complete items 2a - 2d below.
2a. Are you receiving or have you ever applied for military retired or retainer pay?
(Answer "yes" if you are receiving payments from the Department of Veterans
Affairs instead of military retired pay.)
Yes

2b. Was your military retired or retainer pay awarded for disability incurred in combat or
caused by an instrumentality of war?

Yes (If available, attach a copy of notice of award)

2c. Was your military retired or retainer pay awarded for reserve service under Chapter
1223, title 10? [Formerly Chapter 67, title 10]
Yes (If available, No attach a copy of notice
of award)

2d. Are you waiving your military retired pay in order to receive credit for military
service for Civil Service Retirement Benefits?

Yes (See instructions for information about
how to request a waiver and its effect on your
annuity. Attach a copy of your waiver request
to this form.)

Section F - Other Claims Information

1. Have you previously filed any application under CSRS (for retirement, refund, deposit, or voluntary contributions)?
Yes (also complete items 1a and 1b below)
1a. Type of application
Retirement

No
1b. Claim number(s)

Deposit or redeposit

Refund
Voluntary Contributions
2. Have you ever been employed under another retirement system for Federal or District of Columbia employees?
Yes (also complete items 2a and 2b below)
2a. Name of other retirement system

No
2b. Dates of service

From (mm/dd/yyyy)

To (mm/dd/yyyy)

3. Have you ever received compensation under the Federal Employees Compensation Act?
Yes (also complete items 3a, 3b and 3c below)
3a. Compensation claim number
3b. Description of benefit
Scheduled award

No
3c. Dates benefits received
From (mm/dd/yyyy)

To (mm/dd/yyyy)

Total or partial disability

U.S. Office of Personnel Management
Previous editions are usable

OPM 1496A
Revised January 2023

Section G - Direct Deposit/Direct Express And Tax Withholding Information

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
the Treasury. For additional information, see page 6 of the instructions for completing this form. This does not apply to you if your permanent payment address is outside
the United States in a country not accessible via Direct Deposit. Please select one of the following:
Please send my annuity payments to my checking or savings account. (Go to item 2)
Please send my annuity payments to my Direct Express debit card. (Go to Section H)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to Section H)

2. Please provide information about your financial institution below.
2a. Financial institution routing number

2b. Account number

Checking
Savings

2c. Name and address of financial institution

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

Do you want Federal income tax withheld from your annuity payments? (See Section G discussion on page 7 of the instructions.)
Yes (Please include IRS Form W-4P Withholding Certificate
No (Please include IRS Form W-4P showing no withholding)
for Periodic Pension or Annuity Payments)

Section H - Applicant's Certification
Warning
Any intentionally false or willfully misleading statement,
certification, or response you provide in this application is a
violation of the law 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)

U.S. Office of Personnel Management
Previous editions are usable

I hereby certify that all statements made in this application are true to the best of my knowledge and
belief. I have read and understand all of the information provided in the instructions to this application.
Signature (do not print)

Date (mm/dd/yyyy)

Digital Signature Field

OPM 1496A
Revised January 2023

Election of Former Spouse Survivor Annuity or
Combination Current/Former Spouse Annuity
If you were age 62 before May 7, 1985, and your marriage ended before May 7, 1985, you are not eligible to elect a survivor annuity for that former
spouse.

Identification of Applicant
Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

If your former spouse was awarded a survivor annuity by court decree or order, your annuity will be reduced to provide that benefit.
You do not need to elect a survivor annuity for that former spouse.
Election: I elect a reduced annuity to provide a survivor annuity or survivor annuities for my current/former spouse(s) as follows:
Name and address of current/former spouse

Date of marriage (mm/dd/yyyy)

Date of divorce* (mm/dd/yyyy)

Date of birth (mm/dd/yyyy)

Social Security Number

Survivor annuity
equal to
%
of my annuity

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

Survivor annuity
equal to
%
of my annuity

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

Survivor annuity
equal to
%
of my annuity

►

Total (cannot exceed 55% of your unreduced annuity)**
Signature

Digital Signature Field

Date (mm/dd/yyyy)

Information: You may elect a reduced annuity to provide a full (55% of your annuity) or partial (less than 55% of your annuity) survivor annuity for a former spouse, if you were
married to that person for at least nine months and you have at least 18 months of Federal service that was subject to civil service retirement deductions. A former spouse who
marries before age 55 is not eligible for a survivor annuity.
If you are married and elect to provide a partial survivor annuity for a former spouse:

•

You may also elect to provide a partial survivor annuity for your current spouse and/or former spouse(s). However, the sum of all survivor annuities cannot exceed
55% of your unreduced annuity.

•

Your current spouse must consent using OPM Form 1496A, Schedule B, to any election that does not provide him or her with a full survivor annuity.

If you are not married, you may elect partial survivor annuities for one or more former spouses. However, the sum of all survivor annuities cannot exceed 55% of your unreduced
annuity.
To elect a former spouse annuity, do not mark either box in item 1 of Section C of the OPM Form 1496A. Instead, mark item 3. Then complete and attach this OPM Form 1496A
Schedule A, which allows you to elect a benefit for a former spouse or divide the benefit between your current spouse and former spouse(s).
Documents you must attach:
1. Copies of divorce decrees for all former spouses for whom you elect to provide a survivor annuity.
2. If you are married, you must also attach a completed OPM Form 1496A, Schedule B, Spouse's Consent to Survivor Annuity Election.
3. Copy of your marriage certificate.

* If current spouse, enter "Not Applicable."
** The maximum is 50% if you separated from Federal service before October 11, 1962.

U.S. Office of Personnel Management
Previous editions are usable

Schedule A
OPM 1496A
Revised January 2023

Spouse's Consent To Survivor Election
(For retirements commencing on or after May 7, 1985, under the Civil Service Retirement System)
Instructions: If you are married and do not elect a reduced annuity to provide a full current spouse survivor annuity, complete Part 1. If you mark item a, fill in the blank to show
the amount of your annuity that you entered on OPM Form 1496A, Section C. Have your spouse complete Part 2 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 the one box which describes the election you have made with regard to your current spouse.)
a. A partial survivor annuity for my current spouse equal to:
(1) 55% of $ ____________ a year. (This agrees with my election in Section C, item 1B, on my completed OPM Form 1496A.)
(2) __________ % of my annuity. (This agrees with my completed OPM Form 1496A, Schedule A.)
b. No regular survivor annuity for my current spouse, but I am electing an insurable interest survivor annuity for my current spouse. (I have completed Section C,
item 4, on my OPM Form 1496A, naming my current spouse.)
c. No regular or insurable interest
d. A survivor annuity for my former spouse __________________________________________ equal to _______% of my annuity.
(name of former spouse)

Part 2 -To be completed by the applicant
I freely consent to the survivor election described in Part 1. I understand that my consent is final (not revocable).
Name (type or print)

Signature (do not print)

Digital Signature Field

Date of birth (mm/dd/yyyy)

Part 3 -To be completed by Notary Public or other person authorized to take acknowledgments

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

(month)

, at

(year)

(city and state)

Signature

Digital Signature Field

(Seal)

Expiration date of commission, if Notary Public
General Information: Based on Public Law 98-615, a married applicant whose annuity begins on or after May 7, 1985, receives a fully reduced annuity to provide a maximum
survivor annuity for his or her spouse, unless the applicant and the spouse consent to a less than full survivor annuity by signing this form or the Office of Personnel Management
(OPM) approves a waiver of the spousal consent. A court order which requires an applicant 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 applicant can still elect to provide a
survivor annuity for the current spouse even though 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 remarriage before age 55,
under the terms of the court order, or death).
Important: If the current spouse consents to an election to provide no survivor annuity or partial survivor annuity and is later divorced from the retiree, the retiree may not then
elect (nor can OPM honor a court order) to provide a former spouse annuity which exceeds the amount elected at retirement for that spouse.

U.S. Office of Personnel Management
Previous editions are usable

Schedule B
OPM 1496A
Revised January 2023

File Type	application/pdf
File Modified	2022-12-12
File Created	2022-12-12