RI 38-134
April 2002This form may be locally reproduced
(Instructions on the reverse)
Instructions: The Human Resources Office will complete Part 1 of this form and give it to the employee. The employee must indicate
his/her election by signing in Part 3 and returning the signed form to the Human Resources Office on or before the due date shown in
Part 1.
Election to Retain NonAppropriated Fund (NAF) Retirement Coverage
As a Result Of A Move From A NonAppropriated Fund Position To A
Civil Service Position On or After December 28, 2001
Part 2 - Acknowledgement of Receipt and Notice of Effect of Failure to Elect
I understand that I am eligible to retain retirement coverage in the NAF retirement plan shown above. I acknowledge that the Human
Resources Office has completed Part 1 of this election form and given it to me on this date. I understand that if I fail to complete Part 3
and return the completed form to the Human Resources Office before the close of business on the Due Date (shown in Part 1) I will
automatically be considered to have chosen Option 2 in Part 3. I also understand that the option I choose below (or am automatically
considered to have chosen) will restrict my retirement plan entitlement for the rest of my Government career and that I can never change
this election regarding retention of NAF retirement coverage as a civil service employee.
Date (mm/dd/yyyy)Employee's Signature
Part 1 - (To be completed by agency)
I verify that in accordance with §§ 8347(q) and 8461(n) of title 5, U.S.C., and OPM regulations at 5 CFR part 847, this employee is eligible to
retain coverage in the NAF retirement plan because he/she —
Employee's name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
Name of NAF Retirement Plan
Due date (mm/dd/yyyy)
Human Resources Office must receive election on or before
(1) Has never previously had an opportunity to elect to retain coverage in a NAF retirement plan; and
(2) Has moved, on or after December 28, 2001, from a NAF position subject to a NAF retirement plan to a civil service appointment
covered by CSRS, CSRS Offset, or FERS without a break of more than 1 year.
Date of move (mm/dd/yyyy)
Date signed (mm/dd/yyyy)
Authorized Signature
Title
Part 3 - Employee's Election (Instructions to employee: Sign only the box for the option that
you elect.)
Option 1: I elect to retain retirement coverage in the NAF retirement plan. I understand that because of this irrevocable decision, I will
never be able to earn additional credit under the Civil Service Retirement System (CSRS) or the Federal Employees Retirement System
(FERS). I understand that regardless of future moves between NAF and civil service employment, breaks in service, and changes in
employment or retirement status, my retirement coverage will remain with a NAF retirement plan in accordance with the rules of that plan.
Date (mm/dd/yyyy)Employee's signature
Option 2: I do not elect to retain retirement coverage in the NAF retirement plan. Because I have made this decision:
(1) I will enter FERS, CSRS, or CSRS Offset coverage as appropriate. In the future, I may be able to elect to credit my NAF service to
qualify for an immediate FERS, CSRS, or CSRS Offset retirement. I will only be able to make such an election at the time I retire. I
understand that my NAF service will not increase the amount of any future FERS, CSRS, or CSRS Offset annuity to which I may
become entitled.
(2) I will not be given another opportunity to retain coverage in a NAF retirement plan if I ever move from a NAF position to a civil service
appointment in the future. However, if I move back to a NAF position, I will be subject to the NAF plan in accordance with its rules.
(3) If in the future I move back to a NAF retirement covered position without a break in service of more than 1 year, including
employment covered by the NAF retirement plan that I am leaving, I will be given a one-time opportunity (if I never before have been
given the opportunity) to elect to retain coverage in FERS, CSRS, or CSRS Offset as appropriate, or to enter the appropriate NAF
plan without transfer of FERS, CSRS, or CSRS Offset service credit.
Date (mm/dd/yyyy)Employee's signature
