SF 3112 CSRS/FERS Documentation in Support of Disability Retirem

OMB Approval 3206-0228

Documentation in Support of
Disability Retirement Application
This package contains the forms applicants for disability retirement from civilian Federal service need to complete.
You should have received with this package a pamphlet entitled: Information About Disability Retirement.
If you did not receive the information pamphlet, ask your agency to give you one. This package contains the
following forms: Standard Form 3112A, Applicant's Statement of Disability, Standard Form 3112B, Supervisor's
Statement, Standard Form 3112C, Licensed Healthcare Practitioner's Statement, Standard Form 3112D, Agency
Certification of Reassignment and Accommodation Efforts, and Standard Form 3112E, Disability Retirement
Application Checklist.
You should keep one copy each of the completed forms for your own records. Your agency will send the originals of
each form to the Office of Personnel Management (OPM). You must obtain the evidence that will enable OPM to
decide that your disease or injury is so severe that you can no longer perform useful or efficient service, or that you
have a medical condition that requires restrictions from critical duties of your job.
You can help speed the processing of your application. Make sure all the information requested on the forms is
provided. Put a copy of your position description with the forms you give your licensed healthcare practitioner(s).
See that the information you submit contains diagnosis, prognosis, and a treatment plan dated no more than 60 days
before the date your application is filed. Although we accept all medical evidence about your disease or injury,
current evidence provides the best support of your application.
If you are applying for disability retirement under the Federal Employees Retirement System (FERS) or the
Civil Service Retirement System (CSRS) with offset service, you must document that you have applied for Social
Security disability benefits. The application receipt or award notice that you receive when you apply for Social
Security benefits should be attached to your application. Your application cannot be completely processed without
this information. Important: If Social Security awards you benefits, your payments from OPM must be reduced
starting on the date the Social Security award started. Since this may result in an overpayment of OPM benefits, you
should not spend any of the money from Social Security until your annuity from OPM has been reduced and OPM
has billed you for any overpayment. OPM is required by law to collect any annuity overpayment. If any or all of the
overpayment cannot be repaid, OPM may have to start debt collection procedures
If you are not separated from Federal Service, return all the completed forms and associated documents to your
agency's personnel office. Your personnel office will assemble your disability retirement application package and
send it to OPM. Please follow up with your agency to be sure they send your application to OPM.
If you have been separated from Federal service for more than 31 days, you need to give each form to the
appropriate individual and ask that the completed forms be returned to you so you can assemble your disability
retirement application package yourself and send it to OPM at:
U.S. Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045

OPM must receive your application not more than one year after the date you separated from your position. If you are
unable to get all the information requested, do not delay submitting your Standard Form 3112A to OPM. See the
accompanying pamphlet for an explanation of exceptions.

7540-01-385-7215
3112-104

(continued on reverse)

Standard Form 3112
Revised December 2024
Previous editions are not usable

Applicant's Statement of Disability
In Connection With Disability Retirement Under the Civil Service Retirement System or
the Federal Employees Retirement System
A copy of this completed form must accompany the Supervisor's Statement
you give your supervisor(s).
Name (last, first, middle)

4.

Fully describe your disease(s) or injury(ies.) We consider only the diseases and/or injuries you discuss in this application.

5.

Describe how your disease(s) or injury(ies) interferes with performance of your duties, your attendance, or your conduct.

6.

Describe any other restrictions of your activities imposed by your disease or injury.

7a.

What accommodations have you requested from your agency?

7b.

Has your agency been able to grant your request? (Attach an explanation or any documentation that you have regarding accommodation.)

7c.

Yes
What is your current status with your agency?

2.

Date of birth (mm/dd/yyyy)

OMB Approval 3206-0228

1.

3.

Social security number

No

In pay status; and working without accommodation.

In leave without pay status.*

In pay status; and working with accommodation.
Separated from service.*
*If you are currently in a leave without pay status or separated from service, what job(s), if any, have you performed since going into this status?
Please explain the physical and/or mental requirements for this (those) job(s).

8.

Give the approximate date you became disabled for 9.
your position (mm/yyyy).

Have you been hospitalized for your
disease or injury as described in item 4?
Yes

10.

Give date of most recent hospitalization.
From (mm/yyyy)

To (mm/yyyy)

No

11.

Notice for FERS and CSRS Offset Applicants ONLY
Application for disability retirement under FERS or CSRS Offset requires an application for Social Security Disability Benefits. Final processing
at OPM cannot be completed without a copy of your Social Security Disability application, receipt, or award notice.
Have
you applied for disability benefits from the
11b. Is this application receipt or award notice
11a.
Social Security Administration?
attached?
Yes

No

7540-01-385-7215
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

Yes

3112-104

No
Standard Form 3112A
Revised December 2024
Previous editions are not usable

12.

List the licensed healthcare practitioner(s) name(s), address(es), and dates of treatment from whom you plan to request Licensed Healthcare
Practitioner's Statement (SF 3112C). Attach an additional sheet if you wish to list more licensed healthcare practitioners.
Name

13.
Applicant's Consent and Certification

WARNING: Any intentionally false statement in this
application or willful misrepresentation relative thereto 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)

Address

Date of Treatments

I certify that all statements made above are true to the best of my knowledge and belief. I give my
permission for the release of information about my service and medical condition(s) (i.e., disease
or injury) to authorized agency and OPM officials. I have read and understand all of the
information provided in the instructions to this application.

Signature (do not print)
Date (mm/dd/yyyy)

Daytime telephone number

(

)

E-mail address

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. §§ 8342 and 8451, which provide that OPM
will determine whether employees and former employees who apply for disability retirement are eligible for that benefit. 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 the allowance or disallowance of the disability retirement
application. 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 this information were not provided,
OPM would be unable to determine whether the applicant meets the legal requirements for disability retirement.
Public Burden Statement
The public reporting burden to complete this information collection is estimated at 30 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 3206-0228.

3112-104

Reverse of Standard Form 3112A
Revised December 2024
Previous editions are not usable

Supervisor's Statement
In Connection With Disability Retirement Under the Civil Service Retirement System or
the Federal Employees Retirement System
This form should be completed by the immediate supervisor
or someone who is in a position to observe the applicant on a regular basis.

OMB Approval 3206-0228

Instructions
 "Unsatisfactory conduct" means conduct for which an employee may

All sections of this form must be completed properly. Failure to do so will
delay the processing of the disability application at OPM.

be removed or disciplined for cause under adverse action procedures.
(For example, discourteous conduct to the public, behavior which
poses a threat to the life, health, safety, or well-being of co-workers,
subordinates, or the public.)

The employee identified in Section A has indicated that he or she intends
to apply for disability retirement. The applicant's signature on the
"Applicant's Statement" authorizes his or her immediate supervisor
(or a supervisor who was or is in a position to observe the applicant
on a regular basis) to provide the information and documentation
requested. The immediate supervisor is asked to provide information
about the applicant's job, performance, attendance, and conduct.

 "Accommodation" means an adjustment made to a job and/or work

environment that enables a qualified handicapped person to perform
the duties of that position. Reasonable accommodation may include
modifying the work-site, adjusting the work schedule, restructuring
the job, acquiring or modifying equipment or devices, providing
interpreters, readers or personal assistants, and reassigning or
retraining employees.

If you need more space in any section, attach a separate sheet and
indicate that an attachment is provided.

 "5 CFR 531.409(d)" is the regulation that provides for a waiver of the

The following definitions apply to the terms used in the Supervisor's
Statement.

requirements for determination of an employee's level of competence
in certain cases when the employee was in duty status for less than 60
days during the 52 calendar weeks before a within-grade increase
would be due.

 "Less than fully successful performance" means performance of an

employee which fails to meet established performance standards in one
or more critical elements of the employee's position or the equivalent
level for a position not under 5 CFR part 430.

After completing and certifying this form and attaching the appropriate
documentation, you should return the original to the employee or to your
personnel office according to instructions and practices in your agency.
In either case, a copy must be given to the employee. Please do not send
the form directly to OPM unless OPM specifically requested you to do so.

 "Critical element" means a component of an employee's job that is of

sufficient importance that performing below the minimum standard
established by management requires remedial action, such as denial
of within-grade increase, and may be the basis for reducing the grade
level or removing the employee.

If necessary, you may be contacted by OPM for additional information or
clarification.

 "Unacceptable attendance" means absence from work which is too

frequent, unpredictable, or lengthy to allow the job to be done.

Section A - Applicant Identification
1.

1.

Name (last, first, middle)

2.

Date of birth (mm/dd/yyyy)

Section B - Information About Employee's Performance
(See instructions above)
Title of position of record. (Attach a copy of position description and current performance standards.
If available, attach a copy of the latest performance appraisal.)

3.

Social security number

2.

Date of entry into position
(mm/dd/yyyy)

3.

Is performance less than fully successful in any critical element of position?

4.

Yes, complete items 4 - 6 of this section.
No, go to Section C.
Show the approximate date (mm/yyyy) 5.
After the date in item 4, has the employee received a within-grade 5a.
that unacceptable performance or the
step increase or an award based on performance of a critical
inability to do the job began.
element.?
Period the increase or award covered.
To (mm/yyyy)

3112-104
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

Was within-grade increase
granted under 5 CFR 531.40(d)?
(see instructions)

Yes  From (mm/yyyy)

Yes

No

No

Standard Form 3112B
Revised December 2024
Previous editions are not usable

6.

Identify any critical element(s) of the position which employee does not perform successfully or at all. Explain the deficiencies you observed.
Attach supporting documentation such as notice to the employee that performance is less than fully successful or licensed healthcare practitioner's
recommendation regarding medical restrictions.

Section C - Information About Employee's Attendance
1.

Has the employee stopped coming to work?

2.

No
Yes, how long is absence expected to continue (if known)?
Is the employee's attendance unacceptable for continuing in current position?

3.

No
Yes, attendance stopped or became unacceptable on (mm/yyyy):
Explain the impact of employee's absence on your work operations.

4.

How many hours of leave has employee used for apparent medical reasons since date in
item C2? (Attach copies of medical information on which you based your decision to
approve leave, leave records, records of contact with or notices to employee. Include as
much information as possible about specific reasons for leave use.)

Annual

Sick

LWOP

Enter Leave
Hours Used

Section D - Information About Employee's Conduct
1.

Is employee's conduct unsatisfactory?

2.

No, go to Section E.
Yes, conduct became unsatisfactory on (mm/yyyy):
Describe how conduct is unsatisfactory (attach supporting documentation, such as notice to employee of proposed adverse action).

1.

Section E - Accommodation and Reassignment
(Consult with agency Coordinator for Employment of the Handicapped)
What efforts have been made to accommodate the employee in current position?

2.

Has the employee been reassigned to a new permanent position? (If yes, to what position and when?) 3.

4.

No
Yes, to _____________________________ on (mm/yyyy):
No, go to Section F.
Describe the reason for temporary nature of assignment and length of time the employee is expected to occupy the position.

Has the employee been reassigned to "light
duty" or a temporary position?
Yes

Section F - Supervisor's Certification
1.

How long have you supervised the employee?

2.

I certify that all statements made on this Supervisor's Statement
are true to the best of my knowledge and belief.

2a.

Supervisor's signature

2c.

Supervisor's name (type or print legibly)

3112-104

2b.

Date (mm/dd/yyyy)

2d.

Supervisor's office mailing address

2e.

Supervisor's daytime telephone number (including area code)

2f.

E-mail address

Reverse of Standard Form 3112B
Revised December 2024
Previous editions are usable

Licensed Healthcare Practitioner's Statement
In Connection With Disability Retirement Under the Civil Service Retirement System or
the Federal Employees Retirement System
Applicant must attach a copy of the most current position description
OMB Approval 3206-0228

1.

Section A - Identifying Information and Consent
(to be completed by the applicant)
Date of birth (mm/dd/yyyy)
2.

Name (last, first, middle)

If you are currently employed by your agency 4.
or separated for less than 30 days, enter exact
name and address including the name of the
person or office in your employing agency
where this information should be mailed. 
If you have been separated from your
employing agency for 31 days or more
provide your current home address.

3.

Social security number

Enter the exact name and address (including ZIP Code).


5.

Applicant's Consent to Release
Medical Information

I authorize the release to the Office of Personnel Management and my employing agency of
any and all information or records connected with my disability retirement application.

Signature (do not print)

Date (mm/dd/yyyy)

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. §§ 8342 and 8451, which provide that OPM will determine whether employees and
former employees who apply for disability retirement are eligible for that benefit. 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 the
allowance or disallowance of the disability retirement application. 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 this information were not provided, OPM would be unable to determine whether the applicant meets the legal
requirements for disability retirement.
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 3206-0228.
Section B - Medical Documentation (to be completed by licensed healthcare practitioner)

Instructions
The individual identified above is requesting medical documentation that will be evaluated, along with non-medical documentation, in connection with his
or her application for disability retirement from Federal Government service. Please include all objective findings and reports concerning the individual's
condition. This documentation may also be used in determining his or her eligibility for reassignment to a position that he or she is medically able to perform.
A copy of his or her position description is attached for your information.
 Please provide the medical documentation requested under "Medical Documentation Requirements" on your letterhead stationery. It is important that you

respond to every item listed. Enter the item number of the information requested and provide your response. If an item is not applicable to the applicant's
medical condition, enter "Not Applicable." Include in your statement the identifying information in Section A, items 1 through 3, above. Your failure to
provide complete information will delay the processing of your patient's disability retirement application.
 Enclose your report and any attachments in a sealed envelope marked "Medical Disability - Privileged - Private." Please make sure copies of all medical

reports referenced in your statement are included. Send the envelope to the address shown in item 4 above. You may, if you wish, give it directly to the
applicant for delivery to the appropriate office.
 Please complete this statement within 2 weeks. Be sure to sign the report. Include your address and telephone number.
 The applicant is responsible for any costs incurred in connection with providing this documentation.
3112-104
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

(continued on reverse)

Standard Form 3112C
Revised December 2024
Previous editions are not usable

Medical Documentation Requirements

You must provide the following:
1. A comprehensive history of this patient's medical condition(s).
This must include detailed information regarding the symptoms and
history, past and current physical findings, results of laboratory studies
and therapy of this condition(s). The medical documentation must
contain specific information to show why this patient is not able to
perform his or her duties. The medical documentation should not be
conclusory. Provide a discussion of patient compliance with therapy,
response to therapy, and plans for future therapy. Also, provide copies
of pertinent hospitalization summaries and operative reports.
2. Copies of reports of all applicable diagnostic laboratory tests
(e.g., hematologic, chemistry, electrophysiologic, radiologic, nuclear
medicine). In the case of psychiatric disorders, provide the results of
mental status examinations, personality tests, test of cognitive
function, educational evaluation, neuropsychiatric tests, etc.

3. Diagnosis of patient's condition(s). Preferably each diagnosis should be
found in the current publication, "International Classification of
Disease." In the case of psychiatric disorders, diagnostic titles and
codes from the DSM-5(R) should be used.
4. An assessment of the degree to which the medical condition(s) has or
has not become static and an estimate of the expected date of full or
partial recovery or remission.
5. If restrictions have been placed on this patient's activities, please state
what they are, why they have been imposed, and how long you expect
these to be in effect.

General Information
Disability retirement determinations are made in accordance with Federal retirement regulations. A person is entitled to disability retirement benefits only
when the information submitted with the application shows that an employee is unable to perform useful and efficient service because of disease or injury
(1) in the employee's current position or (2) within a vacant position, in the same agency and commuting area at the same grade or pay level and tenure, for
which the employee is qualified for reassignment. Useful and efficient service means fully successful performance of the critical or essential elements of the
position (or the ability to perform at that level) and satisfactory conduct and attendance.

3112-104

Reverse of Standard Form 3112C
Revised December 2024
Previous editions are not usable

Agency Certification of Reassignment and Accommodation Efforts
In Connection With Disability Retirement Under the Civil Service Retirement System or
the Federal Employees Retirement System

OMB Approval 3206-0228

Instructions
The Coordinator for Employment of the Handicapped should review the
Applicant's Statement, the Supervisor's Statement, the Licensed Healthcare
Practitioner's Statement, and any other relevant documentation on file to
determine if reasonable accommodation will enable the employee to
perform fully successful service in his or her current position or whether a
vacant position is available in the agency, at the same grade or pay level in
the same commuting area, for which the employee is qualified for
reassignment. Take special note of the Supervisor's Statement and resolve
any discrepancies between the information on that form and this form.
Telephone numbers for the applicant, the supervisor, and the licensed
healthcare practitioner may be found on their respective statements should
it be necessary to contact them for further information.
If the employee is eligible to retire voluntarily, the employee should be
advised of that fact. In general there is no difference in the payment to a
disabled annuitant and an optionally retired annuitant, nor are there Federal
tax advantages for a disability retiree.
All items must be completed. In items 4, 5, and 6, if you check a box that
requires additional explanation, please provide the explanation and/or
attachment. This will enable us to process the application without delay.

Accommodation (item 4) - Guidance for determining reasonable
accommodations may be found in 29 CFR 1614.203(c).
The documentation supporting your response to item 4 must
include an assessment of the functional and environmental factors
related to the employee's inability to perform at the fully successful level,
unless there are no medical restrictions.
Reassignment (item 5) - Guidance related to reassignment of an applicant
for disability retirement is published in OPM's "CSRS and FERS
Handbook for Personnel and Payroll Offices."
After completing and certifying this form, please attach the appropriate
documentation and return the original to the employee or to your
personnel office according to instructions and practices in your agency.
In either case, a copy must be given to the employee. Please do not send
the form directly to OPM unless OPM specifically requested you to do so
in this case.
Your agency's obligation to continue to try to accommodate or reassign
the employee does not cease with the filing of this certification.
Your efforts should continue. If the accommodation or reassignment
situation changes after the original filing of the certification, you must
notify OPM of the changes.
OPM may contact you for additional information or clarification.

1.

To be completed by Selective Placement Program Coordinator or other authorized agency official.
See instructions at the top of this page
Name of applicant (last, first, middle)
Date of birth (mm/dd/yyyy)
Social security number
2.
3.

4.

Has reasonable effort for accommodation been made? (You must check one statement below.)
No, the medical evidence presented to the agency shows that accommodation is not possible due to severity of medical condition and the
physical requirements of the position. (Attach copies of all medical evidence supporting the statement and explain why conditions prohibit
accommodation. Also, provide a detailed statement of the physical requirements of the position.) Employees should be counseled concerning the
following: The fact that your agency has determined accommodation to be unavailable due to status of a medical condition or due to restriction
imposed by a licensed healthcare practitioner does not guarantee that OPM will reach the same decisions about the approval of a disability
retirement application.
No, the employee's condition does not appear to require accommodation. Medical information presented to agency does not document a
disabling medical condition.
Yes, describe below accommodation efforts made, attach supporting documentation and provide narrative analysis of any unsuccessful
accommodation efforts.

(continued on reverse)
3112-104
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

Standard Form 3112D
Revised December 2024
Previous editions are not usable

5.

Results of agency reassignment efforts (You must check one statement below.)
Reassignment is not necessary because employee's performance is fully successful and there are no medical restrictions which keep the employee
from performing critical duties or from attending work altogether.
Reassignment is not possible. There are no vacant positions at this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications standards.
The employee declined reassignment to a vacant position(s) in this agency at the same grade or pay level and tenure, within the same
commuting area, for which the employee meets minimum qualifications. (Attach a copy of any reassignment offers.)
The agency did not reassign the employee to the vacant position(s) in this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications. The position(s) identified and reason(s) for non-assignment are shown
below.
Position Title

Reason for Non-Reassignment for Non-Selection*

* If the employee's medical condition precludes reassignment to the position, attach documentation. If the reason for non-selection is
intended removal, attach a copy of the removal notice to the employee.
6.

Is the employee currently occupying a temporary position?
No, the employee is occupying a permanent position.
Not applicable, the employee is no longer an employee of the agency.
Yes, state below the nature of these duties, the reason for the temporary status, and length of time the agency expects the employee to occupy
this position.

Certification by Selective Placement Program Coordinator or other authorized agency official.
7.

I certify that this statement is true to the best of my knowledge and belief.

7a.

Signature of responsible agency official

7b.

Title of responsible agency official

7d.

Name of responsible agency official (type or print legibly)

7e.

Telephone number (including area code)

7f.

E-mail address

3112-104

7c.

Date (mm/dd/yyyy)

Reverse of Standard Form 3112D
Revised December 2024
Previous editions are not usable

Disability Retirement Application Checklisht

For Disability Retirement under the Civil Service Retirement System
and the Federal Employees Retirement System
(to be completed by employing agency)
OMB Approval 3206-0228

1.

Name of applicant (last, first, middle)

4.

Do available records show that the employee has at least 5 years of civilian service under the Civil Service Retirement System or at least 18 months
under the Federal Employees Retirement System?
Yes
No
Will employee remain in duty status?
5a. Show the date pay stopped or will stop. (mm/dd/yyyy)

5.
6.

2.

Yes
No
Has employee ever received or made application for compensation
from the Department of Veterans' Affairs?

Date of birth (mm/dd/yyyy)

3.

6a. Claim number

Social security number

6b. Period compensation was received
From (mm/yyyy) To (mm/yyyy)

Yes

7.
8.

No
7b.
Has
the
employee
made application for disability benefits from
FERS and CSRS
the
Social
Security
Administration?
Offset Applicants
No
Yes
Are the following documents attachments attached (Indicate by "X" for each).
7a.

a.
b.
c.

f.

SF 2801 or SF 3107, Application for Immediate Retirement
SF 3112A, Applicant's Statement of Disability
SF 3112B, Supervisor's Statement
Employee's Performance Standards
Employee's Position Description
Supporting documentation regarding employee's performance
Supporting documentation regarding employee's leave use
Supporting documentation regarding employee's conduct
SF 3112C, Licensed Healthcare Practitioner's Statement (or equivalent)
SF 3112D, Agency Certification of Reassignment and Accommodation Efforts
Supporting documentation of Agency's accommodation efforts
Supporting documentation of employee's non-reassignment or non-selection
Agency report of Federal medical examination (if one was made)

g.

Other:

d.
e.

9.

10.

Is the application receipt or award notice attached?
Yes

No

Yes

No

Not
Applicable

Has the supervisor stated the employee's performance is less than fully successfully in any critical element of the position in Section B, SF 3112B?
(1) a copy of the employee's performance appraisal covering the employee's service
Yes 
No
prior to the date shown in Section B, item 5, of the Supervisor's Statement, and
(2) a copy of the performance appraisal covering service after that date, if available.
If the employee is temporarily at an address other than the one given
11. If the employee is unable to act on his own behalf, give the name
on SF 2801 or SF 3107, Section A (such as hospital, nursing home,
and address of the person acting for him or her.
or with a relative), enter that address, including ZIP Code.

Agency Certification
12.

I certify that the information shown above accurately reflects
verified information in official records.

13.

Full Agency name and address (including ZIP Code)

14.

List the full name and address of agency office and official to be notified
of OPM's determination (including telephone number and area code).

12a. Signature of Chief Personnel Officer or Designee
12b. Official Title
12c. E-mail address
12d. Telephone number (incl. area code) 12d. Date (mm/dd/yyyy)
Check here if this address is the same as the address in item 13.
3112-104
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

Standard Form 3112E
Revised December 2024
Previous editions are not usable