RI 30-3 Information Necessary for a Competency Determination (20

OMB Approval 3206-0140

United States
Office of Personnel Management
Retirement Operations
Boyers, PA 16017

Information Necessary for a Competency Determination
An original or a certified copy of a court order appointing a guardian or fiduciary to handle the affairs of the individual should
be submitted so that the Office of Personnel Management can determine whether the applicant is or was mentally incompetent
or otherwise unable to handle his or her financial or other affairs. Uncertified photocopies are not acceptable. The court order
should cover the entire period of time which is in question for this determination and should address whether the alleged
incompetency occurred in the past or is currently present.
If no guardian or fiduciary is appointed by a court, please provide the information described in both A and B below.
A.

A statement from the physician or other licensed health practitioner who has been treating the individual. (The individual
or his representative is responsible for any cost incurred in obtaining this documentation.) The physician's or other
licensed health practitioner's statement should cover, but not be limited to, the time period in question for this competency
determination and should address whether the alleged incompetency occurred in the past or is currently present.
The physician or other licensed health practitioner should provide, on his or her letterhead stationery, the information
listed below. Please provide a copy of this form to the physician or other licensed health practitioner.
• History of the specific medical condition(s) which caused the individual to be incompetent, including symptoms,
physical findings, results of laboratory studies, and therapy (together with the response to therapy). Please provide
copies of all reports of laboratory studies, in the case of psychiatric disorders, the discharge summaries of
hospitalizations and operative reports.
• The diagnosis should be in accordance with International Statistical Classification of Diseases and Related Health
Problems (ICD) terminology or, in the case of psychiatric disorders, with Diagnostic and Statistical Manual of Mental
Disorders (DSM) V criteria.
• The duration of the medical condition(s), including the date the condition caused incompetency and the date or expected
date of full or partial recovery.

B.

Affidavits from at least two persons who know the facts concerning the individual's competency, preferably one from a
member of the individual's immediate family and one from a non-family member. The persons making the affidavits
should state:
• The relationship to, and amount of contact with, the individual during the relevant time period.
• What actions or incidents were personally observed which would show whether the individual's condition interfered
with the ability to handle personal affairs, and how often these were observed.
• The reason why a guardian or fiduciary was not appointed by the court to handle the affairs of the individual.
• Who has been handling the individual's affairs.
(Affidavits must be sworn to or affirmed before a notary public or other officer who is authorized by law to administer
oaths.)

Send the documents to the above address. Be sure to include the claim number shown at the top of form RI 20-7, Representative
Payee Application, with this correspondence.
Warning
Affidavits and other evidence are subject to verification by personal investigation. Any intentionally false statement, willful concealment of a material fact, or use of a writing or
document knowing the same to contain a false, fictitious, or fraudulent statement or entry 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)
Public Burden Statement
The public reporting burden to complete this information collection is estimated at 60 minutes per response, including time for reviewing the collected instructions,
searching data sources, gathering and maintaining the data needed, and completing and reviewing of 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, Retirement Services 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 3206-0140.

Previous edition is not usable

RI 30-3
Revised February 2024