RI 38-144
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 CSRS, CSRS Offset, or FERS Retirement Coverage As a Result Of A
Move From A Civil Service Position To A NonAppropriated Fund (NAF) 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 the civil service retirement coverage 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 civil service retirement coverage as a NAF 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 the civil service retirement plan identified in this part because he/she —
Employee's name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
Name of Civil Service Retirement Plan (CSRS, CSRS Offset, or FERS)
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 that civil service retirement coverage; and
(2) Has moved, on or after December 28, 2001, from a covered civil service appointment to a retirement covered NAF position without a
break in service 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 coverage under the civil service retirement plan identified in Part 1 of this election form. I understand that
because of this irrevocable decision, I will never be able to earn additional credit under any NAF retirement plan. I understand that
regardless of future moves between NAF and civil service employment, breaks in service, and changes in retirement status, my retirement
coverage will remain with the civil service retirement plan identified in Part 1 in accordance with the rules governing that system.
Date (mm/dd/yyyy)Employee's signature
Option 2: I do not elect to retain retirement coverage in the civil service retirement plan identified in Part 1 of this election form. Because I
have made this decision:
(1) I will enter a NAF retirement plan without receiving any service credit in the NAF retirement plan for time spent under that civil service
retirement plan.
(2) I will not be given another opportunity to retain coverage in that civil service retirement plan if I ever move from a civil service
appointment to a NAF position in the future. However, if I move back to a civil service appointment, I will be subject to civil service
retirement coverage (CSRS, CSRS Offset, or FERS) in accordance with the appropriate civil service coverage rules.
(3)
If in the future I move back to civil service employment without a break in service of more than 1 year, I will be given a one time
opportunity (if I never before have had the opportunity) to elect to retain membership in the NAF retirement plan or to become
covered by the appropriate civil service retirement coverage (CSRS, CSRS Offset, or FERS).
Date (mm/dd/yyyy)Employee's signature
