Form RI120-123 Request for Case Review for Enhanced Disability Annuity

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

OMB Approval 3206-0254

Request for Case Review for Enhanced Disability Annuity Benefit
Your full name

If you are receiving a survivor annuity, full name of the former federal employee who performed the service

Claim number (beginning with CSA or CSF)

Your daytime telephone number

Your email address

My annuity benefit includes credit for service performed under the Civil Service Retirement System (CSRS) or the Federal
Employees' Retirement System (FERS) as: (check all that are appropriate)
Law Enforcement Officer
Firefighter
Nuclear Materials Courier performed with the Department of Energy on or after October 1, 1977
Customs and Border Protection Officer on or after July 6, 2008
Member of the Capitol Police
Member of the Supreme Court Police
Congressional Employee
Member of Congress
Air Traffic Controller

We will respond to your request in writing to your address of record.
Retirement Operations
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. Code, Chapter 83, Sections 8337 and 8339, and Chapter 84, Section 8452. Disability retirement benefits
areprovided for individuals who performed service as law enforcement officers, firefighters, nuclear materials carriers, Customs and Border Patrol officers, members of the
Capitol and the Supreme Court police, Congressional employees, and air traffic controllers. 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 review the computations of disability
annuities to includethe formula provided in law for individuals who have performed the aforementioned services. OPM, Retirement Services reviews the annuity computation
and, if the respondentis entitled to an increased benefit, the benefit is authorized. 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 result in
the noncompliance of the provisions of title 5, U.S.CTitle 5, U. S.Code, Chapter 83, Sections 8337 and 8339, and Chapter 84, Section 8452. Individuals who do not provide
this information can also request changes via telephone or letter, as well as using RI 20-123.

Public Burden Statement
The public reporting burden to complete this information collection is estimated at 5 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 3206-0254.
RI 20-123
Previous editions are usable
Revised August 2025