SF 2802 and SF 280 Application for Refund of Retirement Deductions (CSRS) a

Application For Refund of Retirement Deductions
Civil Service Retirement System

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)

3. Social Security Number

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

Yes
No

5. List all other names you have used (if applicable)

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

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. (Note: All civilian and military deposits must be refunded.)
Department or Agency
(Including bureau, branch, or division
where employed)

Location of Employment
(City, state and ZIP code)

Periods of Service

Title of Position

Beginning Date
(mm/dd/yyyy)

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

Ending Date
(mm/dd/yyyy)

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

Not
Withheld

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

Not
Paid

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 14. Have you been divorced on or after May 7, 1985, from a person to whom you were married for at least 9
of Application for Refund of Retirement Deductions, or other information as explained on
months? If "Yes," follow the instructions in the SF 2802A. OPM cannot pay your refund without this
the reverse of SF 2802A. The Office of Personnel Management (OPM) cannot pay your
information.
refund without this information.
No

No

Yes, give name of current spouse:

Yes

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

Previous editions are not usable

Use the space provided on the back of this form to list all such living former spouses.
Standard Form 2802,Page 1
Revised May 2024

Direct Deposit
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 payment 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.

Financial institution routing number
What kind of account is this?

Checking or savings account number

Checking

Savings

Name and address of your financial institution

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
Any intentionally false or
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)

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 employed
again within this period and will return or repay any refund paid to me under those circumstances.
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,
are true to the best of my belief and knowledge.
Your signature (Do not print)

Date

Your Address

Number and street

We cannot authorize payment
to this address if it is erased or
otherwise changed.

City, state, and ZIP code

For agency use only
Signature of agency official
I certify that this agency
received this Standard Form
2802 on the date shown at
Title and Phone Number
the right.

E-mail address

Your area code and telephone number
(
)
Date received

Agency payroll office no.

Standard Form 2802,Page 2
Revised May 2024

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
(mm/dd/yyyy)

Name of Former Spouse

Date of Divorce
(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 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.(See Part II Direct Rollover for more information.)

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.
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.) Do not use this form if you are requesting a balance of your retirement deductions. Send a written request to:
OPM, PO Box 45, Boyers, PA 16017

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

Date of certification (mm/dd/yyyy)

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

Date of certification (mm/dd/yyyy)
Standard Form 2802,Page 3
Revised May 2024

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
Attn: Refund Section
P.O. Box 45
Boyers, PA 16017-0045

Our Internet Address
We provide forms and other information at:
www.opm.gov/retirement-center

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 5 U.S.C., Chapter 83, Section 8342 which provides requirements for payments from the Civil Service Retirement and Disability
Fund of refunds of retirement deductions and/or payments of any other lump sum credit monies to the credit of the eligible individual, plus any interest provided by law. OPM is
authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008). Purpose: The
data you furnish will be used to determine your eligibility to receive a refund of retirement deductions. 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 determine your eligibility to receive a refund of retirement deductions.
Public Burden Statement
The public reporting burden to complete this information collection is estimated at 60 minutes per response, including for reviewing instructions, searching data sources,
gathering and maintaining the data needed, and completing and reviewing the collected information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to the Office of Personnel Management, RS Publications Team at [email protected].
Current information regarding this collection of information – including all background materials -- can be found at https:/www.reginfo.gov/public/do/PRAMain by using the
search function to enter either the title of the collection or OMB Control Number 3206-0128.

Retain this page for your records

Standard Form 2802,Page 4
Revised May 2024

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.

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

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. See Part
II Direct Rollover for more information.

Summary

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:

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.

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.
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 IRAor 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
You choose whether your payment will be made directly to your traditional
for the after-tax employee contributions and earnings on those contributions.
IRA, a Roth IRA, or to an eligible employer plan that accepts your rollover.
You CANNOT roll over after-tax contributions to a governmental 457 plan.
Your payment cannot be rolled over to a SIMPLE IRA or a Coverdell
Education Savings Account because these are not traditional IRA's.

Continued on page 6

Standard Form 2802,Page 5
Revised May 2024

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
will need to contact the TSP Thrift Line Service Center (1-877-968-3778)
or login to your TSP MyAccount (tsp.gov/login) to initiate the rollover
process. You will be sent a rollover form to complete (from the Thrift Line
Service Center representative) or one will be generated from your TSP
MyAccount.
OPM will make your taxable portion of your rollover payment directly to
you the applicant.
Once you as the applicant receive the rollover form (from TSP), the rollover
payment (from OPM) and a distribution notice (from OPM), you will need
to submit all items to the TSP for processing. Applicants must send their
rollover packages to:
Thrift Savings Plan
c/o Broadridge Processing
PO Box 1600
Newark, NJ 07101-1600

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 overall 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 calling1-800-TAX-FORMS.

Standard Form 2802,Page 6
Revised May 2024

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.) Signature date in Part 2 must match the
Signature date in Part 3. Corrections and/or alterations are not permitted. Signatures are required to be original (do not submit a photocopy).
I have read the paragraph above and I Signature (do not print)
understand that the above-named
individual is applying for a refund of
retirement deductions under the Civil Name (Type or print legibly)
Service Retirement System.

Date of birth (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 namedin Part 1in our presence.
Signature
Date of birth (mm/dd/yyyy) Signature
Date of birth (mm/dd/yyyy)
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

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)

Standard Form 2802A, Page 7
Revised May 2024

Notifications 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.
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:

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 where abouts 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.)

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 Public Law 98-615,as amended by Public Law 99-251, provides protection for current and former spouses by requiring the
applicant to notify said persons of the intention to take a refund. Court orders in favor of the financial interests of spouses or former spouses can bar refund payments. OPM is
authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18,2008). Purpose: The
data you furnish will be used to determine your eligibility to receive a refund of retirement deductions. 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, without proof of the notification, OPM
cannot adjudicate this refund application.

Public Burden Statement
The public reporting burden to complete this information collection is estimated at 15 minutes per response, including for reviewing instructions, searching data sources, gathering
and maintaining the data needed, and completing and reviewing the collected information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to the Office of Personnel Management, RS Publications Team at [email protected]. Current
information regarding this collection of information – including all background materials -- can be found at https:/www.reginfo.gov/public/do/PRAMain by using the search
function to enter either the title of the collection or OMB Control Number 3206-0128.

Standard Form 2802A, Page 8
Revised May 2024