RI 20-63 Survivor Annuity Election for a Spouse

OMBApproval 3206-0174

Survivor Annuity Election for a Spouse
Your full name (Please print)

Your claim number

CSA

Please Provide the Following Information About Your Spouse
Spouse's full name (Please print)

Spouse's Social Security Number

Date of marriage (Your election must be received within two years after this

Spouse's date of birth

date)

Election: I elect a reduced annuity to provide a survivor annuity for my spouse named above. I have read and understand the information
in the accompanying letter. I understand that this election terminates if my marriage ends in divorce, annulment, or the death of my
spouse. Pamphlets are available on https://www.servicesonline.opm.gov.

E]

(Choose one of the following as a base for computing the survivor annuity)
I elect the maximum survivor annuity benefit.
I elect a survivor annuity benefit equal to $ _________ per month. (Specify a whole dollar amount.

If my marriage terminates and I want to provide a survivor benefit for a former spouse, I understand that I must file a specific
written election with OPM within 2 years after the date of termination of my marriage.

Important: You Cannot Revoke This Election.
Your signature (Do not print)

Date

Email address

Daytime telephone number

To elect no survivor benefit for your spouse, write your initials in the block provided and sign your name below the block
I have read the enclosed information and have decided not to provide a survivor benefit. I have signed below.

Your signature electing no survivor benefits (Do not print)

Date

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 pursuant to Title 5, U.S.C, Chapter 83, 83390)(5)(C)(i) and (k)(2) and Sections 8416(b) and (c) which state annuitants may elect
to provide survivor annuity benefits for a spouse whom they marry after retirement. 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: OPM is requesting this information to file a specific written election to provide
a survivor annuity. Routine Uses: The information requested on this form may be shared 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 a determination of your disability retirement benefits, 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 is voluntary. However, failure to provide this information may delay or prevent an annuitant from electing survivor
benefits. Individuals who do not provide this information can also request changes via telephone or letter, as well as using RI 20-63. The information collected can only be
obtained from the respondents.

Public Burden Statement
The public reporting burden to complete this information collection is estimated at 45 minutes per response, including for reviewing instructions, searching data
sources, gathering and maintaining the data needed, and the 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 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 OMBControl Number 3206-0174.

Previous editions are not usable.

RI 20-63
Revised October 2024