Form SF 2802; SF 2802A SF 2802; SF 2802A CSRS Application for Refund of Retirement Deductions; Cu

Application For Refund of Retirement Deductions
Civil Service Retirement System
Civil Service
Retirement System

Form Approved:
OMB Number 3206-0128

To avoid delay in payment: (1) Carefully read and comply with all instructions;
(2) Complete application in full;
(3) Typewrite or print in ink.

1. Name (last, first, middle)

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

5. List all other names you have used (including maiden name, if applicable)

3. Social Security Number

4. Are you a citizen of the United
States of America?

6. Previous applications filed
(indicate by "X")

Yes
No

Retirement Annuity

Deposit or Redeposit

Refund

Voluntary Contributions

7. List below all of your civilian and military service for the United States Government or District of Columbia.

Department or Agency
(Including bureau, branch, or division
where employed)

Location of Employment
(City, state and ZIP code)

Title of Position

Periods of Service

Beginning Date
(mm/dd/yyyy)

Ending Date
(mm/dd/yyyy)

Indicate whether
Civil Service
Retirement
deductions were
withheld from your
salary. (Check one)
Withheld

Have you paid
deposit or redeposit
for any period,
including military
service after 1956?
(Check one)
Fully or
Partially
Paid

Not
Withheld

Not
Paid

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8. Have you accepted any further employment with the Federal or District of Columbia government (or arranged for such employment) to become effective
within 31 days from the ending date of your last period of service?
9. If you answered "Yes" to item 8, are Civil Service Retirement System
or Federal Employees Retirement System deductions being withheld
(or will they be withheld) from your salary during such employment?

10. Date of new appointment
(mm/dd/yyyy) (expected
date if not yet employed)

11. Department or agency, including bureau,
branch, or division, in which you are (or will
be) employed

Yes, complete items 9, 10, 11, and 12.
No, skip to item 13.
12. Location of new employment (City, state, and ZIP code)

Yes
No
13. Are you now married? If "Yes," attach SF 2802A, Current/Former Spouse's Notification of
Application for Refund of Retirement Deductions, or other information as explained on the reverse of
SF 2802A. The Office of Personnel Management (OPM) cannot pay your refund without this
information.
No
Yes, give name of current spouse:

U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

14. Have you been divorced on or after May 7, 1985, from a person to whom you were married for at least 9 months? If
"Yes," follow the instructions in the SF 2802A. OPM cannot pay your refund without this information.

No
Yes

Use the space provided on the back of this form to list all such living former spouses.

Previous editions are not usable

Standard Form 2802, page 1

Revised September 2013

Direct Deposit
1. Public Law 104-134 requires that most Federal payments be paid by Direct Deposit through Electronic Funds Transfer (EFT) into a savings or checking account at a financial institution. However, if receiving your payment
electronically would cause you a financial hardship, or a hardship because you have a disability, or because of a geographic, language or literacy barrier, you may invoke your legal right to a waiver of the Direct Deposit
requirement, and continue to receive your payment by check. Therefore, you must select one of the following:
Please send my annuity payments directly to my checking or savings account. (Go to item 2.)
Receiving my payment(s) electronically would cause me a financial hardship, or a hardship because of a disability, or because of a geographic, language or literacy barrier. I hereby invoke my legal right to a waiver of the
Direct Deposit requirements of Public Law 104-134. Please send me my payment(s) by check. (Go to Section J.)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express.
2.

Do you want to have your survivor annuity payments made to the same checking or savings account to which OPM made payments by direct deposit to the deceasedbefore his or her death (must be an active account and you
must be a co-owner)?
Yes
No

3.

Do you want your survivor annuity payments made to a checking or savings account to which we have not already been making payments by direct deposit?

4.

Financial institution routing number (You may obtain this 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.)

5.

Checking or savings account number

Yes

6.

No

What kind of account is this?
Checking

Savings

7. Name and address of your financial institution
-----------------------------------------------------------------------------------------------------------------------------------------------------------8.

Telephone number of your financial institution (including area code)

Special note: If you prefer, you may attach a cancelled personal check that shows the information requested above, 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 the correct information for Direct Deposit. (Some
institutions, especially credit unions, use different routing numbers on checks.) OPM can use this information to start paying you by Direct Deposit.
WARNING
APPLICANT CERTIFICATION: I understand that I am not legally entitled to receive a refund if I am reemployed or otherwise assigned to a position under the Civil
Service Retirement System or Federal Employees Retirement System within 31 days of separating from my most recent position. I agree to notify OPM if I am
Any intentionally false or
employed again within this period and will return or repay any refund paid to me under those circumstances.
misleading statement,
certification, or response you
provide in this application is a
I hereby certify that all statements in this application, including the information I have given pertaining to current and former spouses in items 13 and 14 and on the back,
violation of the law punishable are true to the best of my belief and knowledge.
by a fine of not more than
Date
E-mail address
Your area code and telephone number
$10,000 or imprisonment of not Your signature (Do not print)
more than 5 years, or both.
(18 U.S.C. 1001)
(
)
Your Address
We cannot authorize payment to
this address if it is erased or
otherwise changed.

For agency use only Signature of agency official
I certify that this
agency received this
------------------------------------------------Standard Form 2802 Title
City, state, and ZIP code
on the date shown at
the right.
Number and street

Date received

Agency payroll office no.

Standard Form 2802, page 2
Revised September 2013

Information About Former Spouses
If you answered "Yes" in item 14, list all living former spouses to whom you were married for at least 9 months and from whom you were divorced on or
after May 7, 1985.
Date of Marriage
Date of Divorce
Name of Former Spouse

(mm/dd/yyyy)

(mm/dd/yyyy)

Rollover Election
If your refund is less than $200, we cannot roll it over. We will pay it directly to you. Indicate below how you wish to have your refund paid if it is $200 or
more. Please carefully read all of the information provided with this form, including the Special Tax Notice Regarding Rollovers, before you make your
decision. An error in completing this election could delay your payment or cause payment in a manner you did not intend. If you elect to roll over less than
100% of your refund, the total amount you roll over to any one organization must be at least $500. (Make one choice in each section below, unless you need
additional information. If you need additional information before making this election, check the box in the last section.)
If my total refund is $200 or greater
INTEREST PORTION (taxable portion) of my refund
Pay ALL by check made payable to me, with 20% Federal income tax withholding.

Pay ALL by check made payable to my Individual Retirement Arrangement (IRA) or Eligible Employer Plan. (Your financial institution or employer plan must

complete the financial institution certification below.)
This rollover is to a Roth IRA.
Please withhold 20% Federal income tax.
Name of financial institution or employer plan___________________________________________________________________________________________
Mail the check to

the above institution or plan.

me. I will deliver the check to the above institution or plan.

Pay ALL to my Thrift Savings Plan Account. (You must sign and submit form TSP-60, Request for a Transfer Into the TSP, to OPM. Form TSP-60 is available on
the internet at www.tsp.gov.)
CONTRIBUTION PORTION (after tax portion) of my refund
(The Thrift Savings Plan will not accept this portion of your refund.)
Pay ALL by check made payable to me.

Pay ALL by check made payable to my IRA or Eligible Employer Plan. (Your financial institution or employer plan must complete the financial institution

certification below.)
This rollover is to a Roth IRA.
Please withhold 20% Federal income tax.
Name of financial institution or employer plan___________________________________________________________________________________________
Mail the check to

the above institution or plan.

me. I will deliver the check to the above institution or plan.

I need additional information before I decide.
I elect to have my refund computed and a rollover package with all my options sent to me before I decide how it should be paid. (Electing this option delays
payment of your refund at least an additional 30 days.)

Certification from Financial Institutions or Eligible Employer Plans
Name of institution or eligible employer plan

Address of institution or plan

Account number of IRA or eligible employer plan
Certification: My signature below confirms the account number for the individual named on page 1. As a representative of the financial institution or plan named above, I
certify that this institution or plan agrees to accept the funds described above as a direct trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in
an eligible IRA or eligible employer plan as defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand
that my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated above.
Typed or printed name of certifying representative
Telephone number with area code
Signature of certifying representative
Name of institution or eligible employer plan

Date of certification (mm/dd/yyyy)
Address of institution or plan

Account number of IRA or eligible employer plan
Certification: My signature below confirms the account number for the individual named on page 1. As a representative of the financial institution or plan named above, I
certify that this institution or plan agrees to accept the funds described above as a direct trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in
an eligible IRA or eligible employer plan as defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand
that my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated above.
Typed or printed name of certifying representative
Telephone number with area code
Signature of certifying representative

Date of certification (mm/dd/yyyy)

Standard Form 2802, page 3
Revised September 2013

Notice to Applicant
1. If you have more than five years of service, you may be entitled
to annuity rights which you will forfeit by receiving this refund
unless you are later reemployed subject to the Civil Service
Retirement System or the Federal Employees Retirement
System. (Note: Payment of the refund will end any eligibility
your former spouse(s) may have to coverage under the Federal
Employees Health Benefits Program.) You should also be aware
that even if you are later reemployed, the period of time covered
by the refund cannot be used in computing your future annuity
benefits unless (1) you redeposit the refund, plus interest, to the
retirement fund, or (2) the period(s) covered by the refund ended
before March 1, 1991. (Note: If you receive a refund for a
period of service ending before March 1, 1991, and you later
become eligible for non-disability retirement, you will receive
credit for the service covered by the refund in your annuity
computation — even if you choose not to pay the redeposit by
the time your annuity begins. However, if the redeposit is not
paid, your annuity will be actuarially reduced to reflect
nonpayment of the redeposit.) Refunded service may be used for
annuity title and average salary purposes regardless of when the
service was performed or whether you redeposit the refund.
The amount of the redeposit will be the sum of the refund you
received plus interest from the date the refund was paid to the
date you pay the redeposit (or commencing date of annuity, if
earlier.) The interest you will be charged on this refund will be
equivalent to the rate of interest earned by new retirement fund
investments as determined each year by the Secretary of the
Treasury. Since 1985, this rate has ranged from a low of 3.125%
to a high of 13%.
2. If you were separated on or after October 1, 1956, refund of
retirement deductions is prohibited unless your separation
occurred and your application is received by your employing
office or the U.S. Office of Personnel Management at least 31
days before the earliest commencing date of any annuity for
which you are eligible.

3. Refund of retirement deductions is also prohibited if you are
currently employed in a position subject to Civil Service
Retirement deductions or to Federal Employees Retirement
deductions or will be so employed within 31 days from the date
of the separation on which your claim for refund is based.
4. If you are now or have ever been covered by the Federal
Employees Retirement System, you cannot use this application
to request a refund, even if you are requesting a refund of Civil
Service Retirement deductions. You must use Standard Form
3106, Application For Refund of Retirement Deductions
(Federal Employees Retirement System).

5. If you are (or will be) contesting your separation in an
administrative or judicial procedure which may result in the
retroactive cancellation of your separation, the authority for the
Office of Personnel Management to pay you this refund will also
be cancelled. A refund payment based on a separation that is
subsequently cancelled is an erroneous payment that will be
collected as a debt to the United States.
6. Your refund is not payable until at least 31 days have passed
since your separation.
7. Interest will be paid on your refund if the refund covers more
than one year of service subject to retirement deductions and you
have total civilian service of fewer than five years.
8. This application should not be offered to a financial institution or
other person as collateral or security for a loan. The retirement
law [5 U.S.C. 8346(a)] provides that an employee's retirement
contributions are not assignable. A former employee must apply
for a refund personally and payment must be made directly to
him or her or rolled over into his or her account. However,
outstanding debts to the U.S. Government can, at the
Government's request, be withheld from a refund, provided all
legal requirements are met.
Federal Tax Withholding
Although the refund of your contributions to the Civil Service
Retirement fund is not subject to Federal income tax, any interest
paid on your contributions is taxable in the year it is paid, unless
you roll over the interest portion of your refund to a traditional IRA
or another eligible retirement plan. Any interest paid on your
contributions is taxable in the year it is paid if you roll it into a Roth
IRA. Make any rollover election on page 3 of this form after
carefully reading the Special Tax Notice Regarding Rollovers on
pages 5 and 6.

Where to File Your Application
1. If you have been separated 30 days or less, this application
should be forwarded to the office in which you were last
employed.
2. If you have been separated more than 30 days, forward this
application to:
U.S. Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045
Our Internet Address
We provide forms and other information at:
www.opm.gov/retirement-services/.

Privacy Act Statement
Title 5, U.S. Code, Chapter 83, Civil Service Retirement, authorizes solicitation of this information. The data you furnish will be used to determine your eligibility to receive a
refund of retirement deductions. The information may be shared and is subject to verification via paper, electronic media, or through the use of computer matching programs,
with national, state, local, or other charitable or social security administrative agencies in order to determine and issue benefits under their programs or to report income for tax
purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or potential violation of civil or criminal
law. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number to distinguish between the applicant and people with similar names. If you
do not furnish your Social Security Number, OPM may be unable to determine your eligibility to receive a refund of retirement deductions.
Public Burden Statement
We estimate this form takes an average 45 minutes to complete, including 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 U.S. Office of Personnel Management, Retirement
Services Publications Team (3206-0128), Washington, D.C. 20415-3430. The OMB Number, 3206-0128, is currently valid. OPM may not collect this information and you are
not required to respond, unless this number is displayed.

Retain this page for your records.

Standard Form 2802
Revised September 2013
Page 4

Special Tax Notice Regarding Rollovers
The statements contained in this notice prepared by the Office of
Personnel Management (OPM) are based upon a review of Internal
Revenue Service (IRS) publications, specifically Publications 575,
Pension and Annuity Income, 590, Individual Retirement
Arrangements (IRAs), and 721, Tax Guide to U.S. Civil Service
Retirement Benefits. However, the authority to determine income tax
liability in a particular case is vested with the IRS, not OPM. Any
questions that you may have concerning tax liability in your
particular case should be addressed to the IRS.
This notice is provided to you because all or part of the payment that
you will soon receive from the Office of Personnel Management
(OPM) may be eligible for rollover by you or OPM to a traditional
IRA, a Roth IRA, or an eligible employer plan. A rollover is a
payment by you or OPM of all or part of your lump sum to an eligible
employer plan or IRA. A rollover to a traditional IRA or an eligible
employer plan allows you to continue to postpone taxation of the
lump sum until it is paid to you. You cannot postpone taxation of the
taxable portion of a lump sum payment (that is, any interest that you
receive in addition to the lump sum payment of deductions and/or
voluntary contributions) if you roll it over to a Roth IRA. Your
payment cannot be rolled over to a SIMPLE IRA or a Coverdell
Education Savings Account (formerly known as an education IRA).
An " eligible employer plan " includes a plan qualified under section
401(a) of the Internal Revenue Code, including a 401(k) plan,
profit-sharing plan, defined benefit plan, stock bonus plan, and
money purchase plan; a section 403(a) annuity plan; a section 403(b)
tax-sheltered annuity; and an eligible section 457(b) plan maintained
by a governmental employer (governmental 457 plan).
An eligible employer plan is not legally required to accept a rollover.
Before you decide to roll over your payment to an employer plan, you
should find out whether the plan accepts rollovers and, if so, the types
of distributions it accepts as a rollover. You should also find out
about any documents that must be completed before the receiving
plan will accept a rollover. Even if a plan accepts rollovers, it might
not accept rollovers of certain types of distributions, such as after-tax
amounts. If this is the case and your distribution includes after-tax
amounts, you may wish instead to roll your distribution over to a
traditional IRA or Roth IRA or split your rollover amount between
the employer plan in which you will participate and a traditional IRA
or Roth IRA. If an employer plan accepts your rollover, the plan may
restrict subsequent distributions of the rollover amount or may require
your spouse's consent for any subsequent distribution. A subsequent
distribution from the plan that accepts your rollover may also be
subject to different tax treatment than distributions from OPM. Check
with the administrator of the plan that is to receive your rollover prior
to making the rollover.
If you have a Federal Retirement Thrift Savings Plan account, you
may roll over the taxable portion of your lump sum into that account.
The Thrift Savings Plan (TSP) will not accept non-taxable (after-tax)
monies. To accomplish a rollover to the TSP, you will need to submit
form TSP-60 to us. See Part II Direct Rollover for more information.

• The taxable portion of your payment to a traditional IRA or eligible
employer plan will be taxed later when you take it out of the
traditional IRA or the eligible employer plan. Depending on the type
of plan, the later distribution may be subject to different treatment
than it would be if you received a taxable distribution from OPM.
If you choose to have a payment that is eligible for rollover paid to you:
• You will receive only 80% of the taxable amount of the payment,
because the Office of Personnel Management (OPM) is required to
withhold 20% of that amount and send it to the Internal Revenue
Service (IRS) as income tax withholding to be credited against your
taxes.
• The taxable amount of your payment will be taxed in the current year
unless you roll it over. If you receive the payment before age 59-1/2,
you may have to pay an additional 10% tax.
• You can roll over all or part of the payment by paying it to your
traditional IRA, a Roth IRA, or to an eligible employer plan that
accepts your rollover within 60 days after you receive the payment.
The amount rolled over into a traditional IRA or an eligible employer
plan will not be taxed until you take it out of the traditional IRA or
the eligible employer plan. You cannot postpone taxation of taxable
(pre-tax) amounts rolled over into a Roth IRA.
• If you want to roll over 100% of the payment to a traditional IRA or
an eligible employer plan, you must find other money to replace the
20% of the taxable portion that was withheld. If you rollover only the
80% you receive, you will be taxed on the 20% that was withheld and
that is not rolled over.

Your Right to Waive the 30-Day Notice Period
Generally, neither a direct rollover nor a payment to you can be made
until at least 30 days after your receipt of this notice. Thus, after
receiving this notice, you have at least 30 days to consider whether or
not to have your withdrawal directly rolled over. If you do not wish to
wait until this 30-day notice period ends before forwarding your refund
application to your former agency or OPM, you may waive the notice
period by making an election indicating whether or not you wish to
make a direct rollover.

More Information
I. Payments That Can and Cannot Be Rolled Over
Refund payments are "eligible rollover distributions." This means that
they can be rolled over to a traditional IRA, a Roth IRA, or to an eligible
employer plan that accepts rollovers. They cannot be rolled over to a
SIMPLE IRA or a Coverdell Education Savings Account. Both the
taxable portion (interest) and the after-tax portion (actual retirement
contributions) can be rolled over.
After-tax Contributions. After-tax contributions (your actual retirement
contributions, excluding any interest paid) may be rolled into either a
traditional IRA, a Roth IRA, or to certain employer plans that accept
rollovers of the after-tax contributions. The following rules apply:
a) Rollover into a traditional IRA or a Roth IRA. You can roll over
your after-tax contributions to a traditional IRA or a Roth IRA either
directly or indirectly. The actual retirement contributions being
refunded to you are after-tax contributions. You do not owe any tax
on this amount. Only the interest portion is taxable.

Summary
There are two ways you may be able to receive a refund that is
eligible for rollover.
1) We can make certain payments directly to a traditional IRA or Roth
IRA that you establish or to an eligible employer plan that will
accept it and hold it for your benefit ("Direct Rollover"); or
2) We can make the payment to you.
If you choose a Direct Rollover:
• Your payment made directly to your traditional IRA or eligible
employer plan will not be taxed in the current year and OPM will
not withhold income tax.
• The taxable portion of your payment made directly to your Roth
IRA will be taxed in the year in which the rollover is paid, and OPM
will withhold income tax only if you elect tax withholding.
• You choose whether your payment will be made directly to your
traditional IRA, a Roth IRA, or to an eligible employer plan that
accepts your rollover. Your payment cannot be rolled over to a
SIMPLE IRA or a Coverdell Education Savings Account because
these are not traditional IRA's.

If you roll over after-tax contributions to a traditional IRA, it is your
responsibility to keep track of, and report to the IRS on the
applicable forms, the amount of these after-tax contributions. This
will enable the nontaxable amount of any future distributions from
the traditional IRA to be determined.
Once you roll over your after-tax contributions to a traditional IRA
or a Roth IRA, those amounts CANNOT later be rolled over to an
employer plan.
b) Rollover into an Employer Plan. You can roll over after-tax
contributions to an employer plan using a direct rollover if the other
plan provides separate accounting for amounts rolled over, including
separate accounting for the after-tax employee contributions and
earnings on those contributions. You CANNOT roll over after-tax
contributions to a governmental 457 plan.

Continued on page 6

Standard Form 2802
Revised September 2013
Page 5

If you want to roll over your after-tax contributions to an employer
plan that accepts these rollovers, you cannot have the after-tax
contributions paid to you first. You must instruct OPM to make a
direct rollover on your behalf. Also, you cannot first roll over
after-tax contributions to a traditional IRA and then roll over that
amount into an employer plan.

II. Direct Rollover
A DIRECT ROLLOVER is a direct payment of your refund to a
traditional individual retirement arrangement (IRA), a Roth IRA, or an
eligible employer plan that will accept it. You can choose a DIRECT
ROLLOVER of all or any portion of your refund, as described in Part I
on the previous page. You are not taxed on the taxable portion of your
payment (interest amount) for which you choose a DIRECT
ROLLOVER until you later take it out of the traditional IRA or eligible
employer plan. In addition, no income tax withholding is required for
any taxable portion of your refund for which you choose a DIRECT
ROLLOVER to a traditional IRA or eligible employer plan. You
cannot choose a DIRECT ROLLOVER if your refund payment is less
than $200.
DIRECT ROLLOVER to a Traditional IRA or a Roth IRA. You can
open a traditional IRA or a Roth IRA to receive the direct rollover. If
you choose to have your refund paid directly to a traditional IRA or a
Roth IRA, contact an IRA sponsor (usually a financial institution) to
find out how to have your payment made in a direct rollover to a
traditional IRA or a Roth IRA at that institution. If you are unsure of
how to invest your money, you can temporarily establish a traditional
IRA to receive the payment. However, in choosing a traditional IRA,
you may want to make sure that the traditional IRA you choose will
allow you to move all or a part of your payment to another traditional
IRA or to a Roth IRA at a later date, without penalties or other
limitations. See IRS Publication 590, Individual Retirement
Arrangements, for more information on traditional IRAs and Roth IRAs
(including limits on how often you can roll over between IRAs).
DIRECT ROLLOVER to a Plan. If you are employed by a new
employer that has an eligible employer plan and you want a direct
rollover to that plan, ask the plan administrator of that plan whether it
will accept your rollover. An eligible employer plan is not legally
required to accept a rollover. Even if your new employer's plan does
not accept a rollover, you can choose a DIRECT ROLLOVER to a
traditional IRA. If the employer plan accepts your rollover, the plan
may provide restrictions on the circumstances under which you may
later receive a distribution of the rollover amount or may require
spousal consent to any subsequent distribution. Check with the plan
administrator of that plan before making your decision.
Change in Tax Treatment Resulting from a DIRECT ROLLOVER.
The tax treatment of any payment from the eligible employer plan
or IRA receiving your DIRECT ROLLOVER might be different than if
you received your benefit in a taxable distribution directly from the
Office of Personnel Management (OPM).
Direct Rollover to the Thrift Savings Plan (TSP). If you choose to roll
part or all of the taxable portion of your distribution into your TSP
account, you need to submit form TSP-60, Request for Transfer Into the
TSP, along with your refund application. This form is available on the
internet at www.tsp.gov. Fill out your portion of the form; we will
complete our portion and fax it to the TSP office for processing.
The form must be approved by the Thrift Savings Board and the Board
must notify OPM to transfer the funds.

III. Payment Paid to You
If your payment can be rolled over (see Part I on the previous page) but
the payment is made directly to you, the interest portion is subject to
20% federal income tax withholding (state tax withholding may also
apply). The payment is taxed in the year you receive it unless, within
60 days, you roll it over to a traditional IRA or an eligible employer
plan that accepts rollovers. If you do not roll it over, special tax rules
may apply.
Income Tax Withholding:
Mandatory Withholding. If any portion of your payment can be rolled
over under Part I on the previous page and you do not elect to make a
DIRECT ROLLOVER, OPM is required by law to withhold 20% of the
interest portion (taxable amount). This amount is sent to the Internal
Revenue Service (IRS) as federal income tax withholding. For
example, if you can roll over a taxable payment of $10,000, only

$8,000 will be paid to you because OPM must withhold $2,000 as
income tax. However, when you prepare your income tax return for the
year, unless you make a rollover within 60 days (see "Sixty-Day
Rollover Option" below), you must report the full $10,000 as a taxable
payment from OPM. You must report the $2,000 as tax withheld, and it
will be credited against any income tax you owe for the year. There
will be no income tax withholding if your payments for the year are less
than $200.
Sixty-Day Rollover Option. If you receive a payment that can be rolled
over under Part I on the previous page, you can still decide to roll over
all or part of it to a traditional IRA, a Roth IRA, or to an eligible
employer plan that accepts rollovers. If you decide to roll it over, you
must contribute the amount of the payment you received to a traditional
IRA or eligible employer plan within 60 days after you receive the
payment. The portion of your payment that is rolled over will not be
taxed until you take it out of the traditional IRA or the eligible
employer plan. Tax on a Roth IRA rollover must be paid in the year the
rollover is made.
You can roll over up to 100% of your payment that can be rolled over
under Part I on the previous page, including an amount equal to the
20% of the taxable portion that was withheld. If you choose to roll over
100%, you must find other money within the 60-day period to
contribute to the traditional IRA or the eligible employer plan, to
replace the 20% that was withheld. On the other hand, if you roll over
only the 80% of the taxable portion that you received, you will be taxed
on the 20% that was withheld.
Example: The taxable portion of your payment that can be rolled over
under Part I on the previous page, is $10,000, and you choose to have it
paid to you. You will receive $8,000, and $2,000 will be sent to the
IRS as income tax withholding. Within 60 days after receiving the
$8,000, you may roll over the entire $10,000 to a traditional IRA or an
eligible employer plan. To do this, you roll over the $8,000 you
received from OPM, and you will have to find $2,000 from other
sources (your savings, a loan, etc.). In this case, the entire $10,000 is
not taxed until you take it out of the traditional IRA or an eligible
employer plan. If you roll over the entire $10,000, when you file your
income tax return you may get a refund of part or all of the $2,000
withheld.
If, on the other hand, you roll over only $8,000, the $2,000 you did not
roll over is taxed in the year it was withheld. When you file your
income tax return, you may get a refund of part of the $2,000 withheld.
(However, any refund is likely to be larger if you roll over the entire
$10,000.)
Additional 10% Tax If You Are under Age 59-1/2. If you receive a
payment before you reach age 59-1/2 and you do not roll it over, then,
in addition to the regular income tax, you may have to pay an extra tax
equal to 10% of the taxable portion of the payment. The additional
10% tax generally does not apply to (1) payments that are paid after
you separate from service with your employer during or after the year
you reach age 55, (2) payments that are paid because you retire due to
disability, (3) payments that are paid directly to the government to
satisfy a Federal tax levy, (4) payments that are paid to an alternate
payee under a qualified domestic relations order, or (5) payments that
do not exceed the amount of your deductible medical expenses. See
IRS Form 5329 for more information on the additional 10% tax.

Additional Tax Information
This notice summarizes only the federal (not state and local) tax rules
that might apply to your payment. The rules described above are
complex and contain many conditions and exceptions that are not
included in this notice. Therefore, you may want to consult with the
IRS or a professional tax advisor before you take a payment of your
refund from OPM. You can find more specific information on the tax
treatment of payments from qualified employer plans in IRS
Publication 575, Pension and Annuity Income, and IRS Publication
590, Individual Retirement Arrangements. For an overview of the tax
consequences of payments from the Civil Service Retirement System
and Federal Employees Retirement System, you can also consult IRS
Publication 721, Tax Guide to U.S. Civil Service Retirement Benefits.
These publications are available from your local IRS office, on the
IRS's Internet Web Site at www.irs.gov, or by calling
1-800-TAX-FORMS.
SF 2802
Revised September 2013
Page 6

Current/Former Spouse's Notification of Application for Refund of Retirement Deductions

Under the Civil Service Retirement System

If you apply for a refund of retirement deductions, you must notify your current spouse. Also, you must notify any former spouse from whom you were
divorced on or after May 7, 1985, if the following conditions apply: (1) You have 18 months of creditable civilian service; and (2) You were married to the
former spouse for at least 9 months. Refer to the information and instructions given on the other side of this form.

Part 1 - To Be Completed By Applicant
Instructions: To notify each current or former spouse of your application for a refund of your retirement deductions, complete Part 1 with your name, date
of birth and Social Security Number and have the current or former spouse complete Part 2. The current or former spouse's signature must be witnessed in
Part 3. You may not be a witness. After Parts 2 and 3 have been completed, the form must be returned to you for attachment to your refund application. (Use
a separate form for current spouse and each former spouse.)
Name (Last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

Part 2 - To Be Completed by Current or Former Spouse
Instructions: Complete Part 2 and have two witnesses complete Part 3 and then return the form to the applicant. Payment of the refund of retirement
deductions will end any entitlement you may have to a survivor annuity or portion of any annuity to which the applicant would otherwise have been entitled.
If a court order expressly relates to the applicant's retirement deductions and you believe that payment of the refund would end a court-ordered entitlement
you have to a survivor annuity or to a portion of an annuity to which the above-named person is entitled, see the information provided below regarding such
court orders. (Complete Part 2 and have the witnesses complete Part 3 even if you are submitting a court order.)
I have read the paragraph above and I Signature (do not print)
understand that the above-named
individual is applying for a refund of
Name (Type or print legibly)
retirement deductions under the Civil
Service Retirement System.

Date signed (mm/dd/yyyy)

Part 3 - To Be Completed by Witnesses
We, the undersigned, certify that Part 2 of this form was signed by the current or former spouse of the person named in Part 1 in our presence.
Signature
Date signed (mm/dd/yyyy)
Signature

Name of witness (type or print legibly)

Name of witness (type or print legibly)

Address (Number and street)

Address (Number and street)

City, state and ZIP code

City, state and ZIP code

Date signed (mm/dd/yyyy)

Information About Sending Court Orders to the Office of Personnel Management (OPM)
If you are legally separated or divorced from the applicant, you should
know that a refund would end your potential entitlement to a survivor
annuity and to any portion of any annuity to which the applicant would be
entitled. If you have a court order that expressly relates to any portion of the
applicant’s retirement deductions, you should send a copy of the court
order to OPM with a cover letter giving:
1. The name, date of birth, and Social Security Number of the person
applying for the refund;
2. Your statement that the court order has not been amended, superseded, or
set aside.
3. Your name, date of birth, and mailing address; and
4. If the court order states that any payments to you are subject to
termination upon your remarriage, a statement that either (1) you have
remarried and the date of the remarriage, or (2) that you have not
remarried and that you will notify OPM within 15 days after any
remarriage in the future.
If the court order gives you a survivor annuity after the death of the
applicant, also attach a copy of your birth certificate, if available.

The court order can be honored only if it is received before the refund is
paid to the applicant. Payment of the refund will end any entitlement you
may have to a survivor annuity or a portion of any annuity to which the
applicant would otherwise have been entitled. Payment of the refund will
also end any eligibility you have to coverage under the Federal Employees
Health Benefits Program. Send a copy of the court order and your cover
letter to the following address and complete the blocks below:
Office of Personnel Management
Retirement Operations Center
Attn: Refunds
P.O. Box 45
Boyers, PA 16017-0045
A former spouse who remarries before reaching age 55 is not entitled to a
survivor annuity, unless you and the applicant were married for at least
30 years and you remarried on or after January 1, 1995. (Termination of the
remarriage does not restore a former spouse’s entitlement to a survivor
annuity.) Remarriage does not affect a former spouse’s court-ordered right
to receive a portion of any annuity during the annuitant’s lifetime, unless the
court order provides otherwise. A former spouse may also lose entitlement
according to the court order.

I believe I have a court order that meets the criteria described above. I am immediately submitting a copy of the court order and the required cover letter to
the address provided above.
Signature (Do not print)

U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel
and Payroll Offices

Date of court order (mm/dd/yyyy)

Today's Date (mm/dd/yyyy)

SF 2802A
Revised September 2013
Previous editions are not usable

Notification To Current and Former Spouses of Your Refund Application
The Civil Service Retirement law provides that your retirement
contributions may be refunded to you only if you notify the following
persons that you are applying for a refund:
• any current spouse (including any person from whom you are
legally separated) and
• any former spouse from whom you were divorced on or after
May 7, 1985.
You are not required to notify a former spouse if you were not married to
that person for a total of at least 9 months or you do not have a total of at
least 18 months of creditable civilian service.
You should provide a copy of Standard Form 2802A, Current/Former
Spouse’s Notification of Application for Refund of Retirement
Deductions (this form, front and back), to (1) your current spouse,
if any, and (2) if you have at least 18 months of creditable civilian
service, each former spouse that meets the above criteria. The current
and/or former spouse(s) must sign the form and have the signature
witnessed by two persons. You cannot be one of the witnesses.
Additional copies of the SF 2802A should be available from your
employing office or you can photocopy both sides of the form for each
spouse/former spouse.
In addition, the law provides that payment of your refund is subject to
the terms of any court order (related to a divorce or legal separation)
that expressly relates to any portion of your refund, if the payment of
the refund would end the entitlement of a spouse or former spouse to
a survivor annuity or a portion of your annuity. A court order cannot
bar payment of a refund if you do not have a future annuity entitlement
under the Civil Service Retirement System.
Attach all signed and witnessed notification forms to your refund
application.

1. Affidavits signed by two individuals who witnessed your attempt to
personally notify the current or former spouse. The witnesses must
attest that they saw you give or try to give (personally) the
notification form to your current or former spouse to whom your
purpose should have been clear.
or 2. The current mailing address of the current or former spouse. (You
may use the box at the end of this column to give the address.) The
Office of Personnel Management (OPM) will attempt to notify (by
certified mail return receipt requested) the current or former spouse
at the address you give. OPM will not pay you the refund until we
receive the signed return receipt. If the notice is undeliverable at the
address you give, your refund may not be paid unless you
subsequently show that the notification requirement should be
waived as described below. If you decide you want OPM to make
notification, it will cause a 6- to 8-week delay in the payment of
your refund.
If you do not know the current whereabouts of a spouse or former spouse,
OPM may waive the requirement to notify that person. A waiver may be
granted if you submit with your refund application:
1. A determination by a court or administrative agency empowered to
make such determinations that the person is missing; or
2. Notarized statements from yourself and two other persons (one of
whom is not related to you) stating that the person’s whereabouts
are unknown and detailing efforts to locate the person.
I have been unable to notify the following current or former spouse.
(Enter name and current mailing address, including ZIP code, of the
current or former spouse.)

If your current or former spouse refuses to acknowledge the notification or
you are otherwise unable to obtain the acknowledgment, you must submit
one of the following:

Privacy Act Statement

Public Law 99-335, which established current and former spouse notification requirements, authorizes solicitation of this information. This information may
be shared with national, state, local, or other charitable or social security administrative agencies to determine and issue benefits under their programs or
when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of the
Social Security Number to distinguish between the applicant and people with similar names. The Government may use your number in collecting and
reporting amounts that you owe the Government. Failure to provide information may delay or prevent refund of your retirement deductions.
Public Burden Statement

We estimate this form takes an average 15 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 U.S. Office of Personnel Management, Retirement Services Publications Team (3206-0128), Washington, D.C. 20415-3430. The OMB Number
3206-0128 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Reverse of SF 2802A
Revised September 2013