Form RI25-15 Self-Certification of Full-Time School Attendance for th

OMB Approval 3206-0042

Self-Certification of Full-Time School
Attendance for the School Year

U.S. Office of Personnel Management
Retirement Surveys & Students Branch
1900 E ST NW
Washington, DC 20415-3563
Student Name

Student Date of Birth

Student Social Security Number

Claim Number

Currently Certified
Through

Date

For Agency Use Only

I

II

III

IV

IMPORTANT: Please read enclosed instructions before completing this form. To avoid interruption of payments, complete this form
immediately and for the entire school year (not just one semester), if plans are known. Do not take this form to the school. The person in
the address above must sign. This is a personalized form, pre-coded for only the student shown. Please return this form in the enclosed
envelope or fax it to (202) 606-0022. If you have any questions about this form, you can call our office at (202) 606-0249 or toll free at
1-888-767-6738. (Hearing impaired users should utilize the Federal Relay Service by dialing 711 or their local communications provider
number to reach a Communications Assistant.) You can also write to OPM at the address shown above.

1. Is the pre-printed student information listed above correct?

Yes

No (Fill information below.)

2. If any of the events shown below apply, fill in the appropriate oval and write down the date the event occurred.
Reduced attendance to less than full-time
Stopped attendance (except scheduled school breaks)
Deceased
Entered military service on active duty
Entered a U.S. military academy
Married
Transferred to a non-recognized school (e.g. elementary schools, correspondence schools, U.S. Military Academies,
or any training program where a one receives pay primarily as an employee.)
Date (mm/dd/yyyy):
If any events above were selected, you may skip the rest of the questions to sign and return this form.
3. Are you returning to school or have returned to school full time on or after the date shown above?
Yes (If yes, please complete the rest of the form.)
No
4. Please provide school name and address, including ZIP code:

5. Enter the date the student began or will begin full-time
school attendance for the school year you are certifying.
Date should be on or after date shown in the pre-printed
section above.

6. Enter the date this school attendance will end or ended. If
the student plans to attend for the full school year, you
should show the ending date of the full school year (NOT
the semester).

Date (mm/dd/yyyy):
7. Is the date given in item 6 the end of the school year?

Date (mm/dd/yyyy):
Yes

No

8. Does the student intend to return to school full-time after the date shown in item 6, with less than a five month break?
Yes (Fill out item 9.)
Undecided
No
RI 25-15
Revised December 2025

9. Enter estimated date the student will attend for NEXT school year after the year shown in items 5 - 6.
Date (mm/yyyy):
Attendance for School shown in item 4. (Mark only one A or B below)
A: Classroom Hours per week, such as for High Schools or trade schools. (Combine work/study hours if in a high school
work study program.)
B: Credit Hours such as for college.
Total Hours:
Type of School shown in item 4.
High School

Trade/Technical/Vocational

Jr. College/College/Community College/University

Other. Indicate type of school:
Is the student in a school-sponsored co-op or internship program?
Yes (Attach a brochure explaining the program or list the program's website below.)

No

WARNING: Any intentionally false statements or willful misrepresentations are punishable by fine, imprisonment, or both
(18 USC 1001).
I certify that all information given in this certification is true and correct to the best of my knowledge and belief. I understand that I must immediately notify
the Office of Personnel Management (OPM) if the student transfers to another school, discontinues school attendance, reduces attendance to less than
full-time, marries or dies. I agree to return all overpayments of student benefits, including overpayments that may be made after I notify OPM of any
terminating event. I authorize the appropriate school official to verify my school attendance status to OPM in the manner requested by OPM (e.g., by
telephone, fax, email, or written correspondence).

Signature of Student (18 years or older) or Person receiving payments if student is a minor or disabled

Date

Email Address

Daytime Phone Number

Privacy Act Statement
• The main authorities that permit the collection of your information include 5 USC 8341, 5 USC 8441, and EO 9397 as amended by EO 13478.
• The main purpose of collecting your information is to confirm your eligibility for student survivor benefits. If you provide your SSN, it will be used to help
identify your account.
• OPM may disclose including identifying information, pursuant to the following principal routine uses: to determine, verify, and provide benefits; for taxes;
to collect debts and/or overpayments; to your representatives; for research; to eliminate fraud and abuse; to the MSPB or OSC for their review; when
necessary and relevant to a legal proceeding; to respond to a Congressional inquiry; for record keeping; to investigate, respond to, or remunerate a
suspected or confirmed breach; and to OPM contractors or similar to assist with accomplishing agency functions.
• Providing this information is voluntary but necessary to process your application for benefits.
• The OPM system of records notice for this collection is OPM/Central—1, Civil Service Retirement and Insurance Records. The full text, including a
complete list of routine uses is available at www.opm.gov/privacy.
Public Burden Statement
The public burden to complete this information collection is estimated at 30 minutes per response, including time 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 3206-0042.
RI 25-15
Revised December 2025