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OMB No. 3206-0121
Form Approved
OPM Form 1496
Revised October 2002
Prior editions are not usable.
UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
OFFICE OF RETIREMENT PROGRAMS
BOYERS, PA 16017
Date of birth
Date of separation giving eligibility
Commencing date of annuity
YOU MAY BE ELIGIBLE FOR DEFERRED RETIREMENT
Records on file with the Office of Personnel Management (OPM) indicate that you may be eligible for a deferred annuity beginning on the
"commencing date" shown above. To apply for your annuity, complete the enclosed Application for Deferred Retirement and return it to
OPM. See the instructions below.
Your annuity will be computed under the law in effect on the date of the separation on which your eligibility for annuity is based, using your
service listed below (unless we can verify additional service). If you have additional Federal service, list it in Section D of the enclosed
application and send us copies of any documents you may have to support your claim to that service.
A decision on your eligibility for an annuity and the amount of service to your credit will be made after we receive your application.
Department or Agency and Location
Beginning Date
(mm/dd/yyyy)
Ending Date
(mm/dd/yyyy)
Civil Service Retirement Deductions were:
Withheld Not Withheld Refunded
Remarks:
Keep the instructions (pages 1 thru 8) for your files.
Return this letter with your completed application in the
enclosed envelope or address them to:
Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045
Retirement Operations Center
Go to Form
APPLICATION FOR DEFERRED RETIREMENT
(Separations before October 1, 1956)
INTRODUCTION
This package is for your use if you are a separated Federal employee
who wants to apply for deferred annuity based on a separation from
service covered by Civil Service Retirement law before October 1,
1956. This package does not include any information on the
provisions of the Federal Employees Retirement System Act of 1986.
Review all information carefully before you complete the application.
Special information which applies only to certain separated Members
of Congress and congressional employees has not been included. Keep
the information sections of this package for future reference.
ELIGIBILITY FOR DEFERRED ANNUITY
If you die before attaining age 62, or after age 62 but before applying
for annuity, the only benefit payable will be your lump sum credit in
the retirement fund; monthly survivor annuity will not be available.
Deferred annuity is payable commencing the day the former Federal
employee is 62, provided an application has been submitted to the
Office of Personnel Management (OPM) and approved. Your
"retirement date" is your 62nd birthday even if you did not apply for
your annuity before you were 62.
Final separation on/after January 24, 1942, but before April 1,
1948, from service covered by the Civil Service Retirement law
entitles you to an annuity if:
1. You had at least 5 years of creditable civilian Federal service or a
combination of creditable civilian Federal service and military
service equaling 5 years, as of your final separation.
2.
You have not forfeited entitlement by drawing a refund of your
retirement deductions covering your final period of service.
If OPM determines that your final separation during the period
specified above was involuntary, not for cause, your annuity may
begin at age 55.
Final separation on/after April 1, 1948, but before October 1,
1956, from service covered by the Civil Service Retirement law
entitles you to an annuity if:
1. You had at least 5 years of creditable civilian Federal service as of
the date of your final separation.
2.
You have not forfeited entitlement by drawing a refund of your
retirement deductions covering your final period of service.
3.
In addition, if the final separation on which your entitlement is
based was on/after August 31, 1954, you must have been covered
by the retirement law for at least one year out of the two-year
period preceding your final separation.
If your final period of service does not meet the "one out of two"
requirement, it will be eliminated from consideration. Retirement deductions
withheld during the period will be refunded, and, if possible, entitlement will
be based on a previous separation.
INSTRUCTIONS FOR COMPLETING APPLICATION FOR
DEFERRED ANNUITY
Section A - Identifying Information
Item 1: Type or print your name clearly.
Item 2: List other names under which you have been employed in the
Federal government (such as a maiden name). This will make it
possible for us to locate and identify records maintained under
such names.
Item 3:
Enter the address to which correspondence should be mailed. (If
you want your payments sent to a bank, do NOT enter that address
here; refer to page 7 for information about how to do this.)
Item 4:
Give a telephone number where you can be reached in case more
information is needed.
Item 5:
Give your date of birth, showing the month, then the day, then the
year. Your retirement records are filed by your name and date of
birth. If your date of birth is not correct on the letter with this
package, send proof of your date of birth (such as your birth
certificate) with your application.
Item 6:
Enter your social security number. The Treasury Department
requires us to report, by social security number, the amount paid to
each annuitant.
Item 7:
Indicate your citizenship.
Section B - Marital Information
Item 1: Indicate whether or not you are married now. If you are married,
also complete Items 1a-1f with information about your current
marriage. Information about your marital status and your spouse is
necessary to assure that you get the survivor election that you want
and to which you are entitled by law.
Item 1a:
Enter your spouse's name.
Item 1b:
Enter your spouse's date of birth (month-day-year).
Item 1c:
Furnish your spouse's social security number.
Item 1d:
Enter the place of your marriage (town or city and state).
Item 1e:
Enter the date of your marriage (month-day-year).
Item 1f:
If you were married by a clergyman or justice of the peace, check
that box. If not, check the box marked "other" and explain how, or
by whom, you were married.
Item 2:
Indicate whether you have a living former spouse whose marriage
to you ended by divorce or annulment on or after May 7, 1985,
and to whom a court order gives a survivor annuity. If you answer
"yes," you must submit a certified copy of the court order and any
attachments or amendments.
Page 1
OPM Form 1496
Revised October 2002
Section C: Annuity Election
To be eligible for a survivor annuity after your death, your widow(er)
must have been married to you for a total of at least 9 months. The
marriage duration requirement does not apply if your death is accidental
(as defined under the retirement regulations) or your surviving spouse is
a parent of your child.
Box 1: Spouse Survivor Benefit
If you initial either Box 1A or Box 1B, your wife or husband will
receive a survivor annuity upon your death. The amount of this survivor
annuity and the amount of the reduction in your annuity to provide this
benefit depend on the box you initial. For a full discussion of the effect
of court orders, see Important Information About Annuity Election on
page 3.
Box 1A: Maximum Survivor Benefit
If you initial Box 1A, you are electing the maximum survivor benefit.
Your spouse's survivor annuity upon your death will be 55% of all of
your annuity. Your annuity will be reduced by 2-1/2% of the first
$3,600 and 10% of the remainder of your annual annuity to provide this
benefit upon your death.
Box 1B: Less than Maximum Survivor Benefit
If you initial Box 1B, you must complete and attach OPM Form 1496,
Schedule B, Spouse's Consent to Survivor Election. The law requires
consent of the spouse if a married person elects less than the maximum
survivor benefits. (See Important Information About Annuity Election
on page 3 for exceptions to the consent requirements.)
If you initial Box 1B, your spouse's survivor annuity upon your death
will be 55% of the annual amount you specify in the blank space (which
must be less than the full amount of your annual annuity). Your annuity
will be reduced by 2-1/2% of the first $3,600 and 10% of any additional
amount you specify.
Box 2: No Survivor Benefit
If you are married and initial Box 2, you must also complete and attach
to your application OPM Form 1496, Schedule B, Spouse's Consent to
Survivor Election. The law requires that your spouse consent if you
elect less than the maximum or no survivor annuity. (See Important
Information About Annuity Election on page 3 for exceptions to the
consent requirement.)
If you initial Box 2, you will receive an annuity payable only during
your lifetime, without monthly survivor annuity for your spouse. All
applicants, married and unmarried, may choose this type of annuity.
However, you should review carefully all information provided here
before making your election.
Box 3: Former Spouse or Combination Current/Former Spouse
Benefit
You are not eligible to elect a survivor annuity for a former spouse if the
dates of your 62nd birthday and of the divorce or annulment were both
before May 7, 1985.
If you initial Box 3, you must use OPM Form 1496, Schedule A,
Election of Former Spouse Survivor Annuity or Combination Current/
Former Spouse Annuity, to make your election. Read the information at the
bottom of Schedule A. You are not permitted to elect a benefit for a former
spouse who has remarried before reaching age 55. Complete OPM Form
1496, Schedule B, Spouse's Consent to Survivor Election, if you are
married and initial Box 3. (See Important Information About Annuity
Election for exceptions to the consent requirements.)
If you initial Box 3, after your death, the person(s) you elect will receive
the percentage of your annuity you select. Your annuity will be reduced by
2-1/2% of the first $3,600 and 10% of the remainder as you specify.
Box 4: Insurable Interest Survivor Benefit
If you were 62 before May 7, 1985, and you were married at age 62, you are
not eligible to check Box 4.
If you initial box 4, a person selected by you at retirement, who has an
insurable interest in you, will receive a survivor annuity upon your death.
Insurable interest exists if the person named (such as a close relative) may
reasonably expect to derive financial benefit from your continued life. Enter
the requested information about the person selected on your application.
You must submit medical evidence that you are in good health. If you
initial Box 4, we will send you a notice describing the medical evidence you
must submit.
If you choose this type of annuity, the amount of the reduction in your
annuity will depend upon the difference between your age and the age of
the person named as survivor annuitant, as shown in the table below. The
survivor's rate will be 50% of your reduced annuity.
Age of Person Named
in Relation to That of
Retiring Employee
Reduction in
Annuity of
Retiring Employee
Older, same age, or less than 5 years younger..................................10%
5 but less than 10 years younger......................................................15%
10 but less than 15 years younger.....................................................20%
15 but less than 20 years younger.....................................................25%
20 but less than 25 years younger.....................................................30%
25 but less than 30 years younger.....................................................35%
30 or more years younger.................................................................40%
If you were 62 on or after May 7, 1985, you may elect an insurable interest
survivor annuity for another person in addition to a regular survivor annuity
for a current or former spouse. However, if you elect an insurable interest
for your current spouse, you must both jointly waive the current spouse
annuity. If you elect the insurable interest annuity for a current spouse
because a court order awards (or you have elected) the regular survivor
annuity to a former spouse, the insurable interest election for your current
spouse can be converted to a current spouse annuity if the former spouse
loses entitlement to the regular annuity through death or remarriage prior to
reaching age 55. The marriage duration requirement does not apply to
insurable interest annuities.
Page 2
OPM Form 1496
Revised October 2002
Important Information About Annuity Election
If you are married at retirement and do not indicate your annuity
election, you will receive an annuity reduced to provide the maximum
survivor benefit (as though you had initialed Box 1A). If you are
married at retirement and elect less than the maximum survivor benefits
for your spouse (that is, you choose 1B, 2, 3, or 4, described above), the
law requires that your spouse consent on OPM Form 1496, Schedule B,
Spouse's Consent to Survivor Election, unless the consent requirement
does not apply to you. Your application will be processed on the basis
of maximum survivor benefits if this form is required but is not
attached.
May 7, 1985
Notice to Applicants Whose 62nd Birthday was Before
If your 62nd birthday was before May 7, 1985, you may not elect a
survivor annuity for a former spouse unless your marriage terminated
on or after May 7, 1985. Also, you do not need your spouse's consent to
elect an annuity without survivor benefit for your spouse or an annuity
with less than the full survivor benefit for your spouse.
If (1) your 62nd birthday was on or after January 5, 1981, (2) you are
still married to the person to whom you were married on your 62nd
birthday, and (3) you wish to elect an annuity with less than the full
survivor benefit or no survivor benefit for that spouse, you must enclose
with your application either--
A written declaration signed by your spouse and two witnesses to
the signature (you cannot be one of the witnesses) stating that he or
she is aware that you have elected an annuity without survivor
benefit (or with less than full survivor benefit) for your surviving
spouse; or
Your spouse's current or last-known mailing address.
are electing less than the maximum survivor annuity.
Use the attached Schedule C if you need to notify your spouse that you
Notice to Married Applicants Who Married After Age 62
Your current spouse is a spouse you married after retirement. If you
wish to elect him or her a survivor annuity, you may do so with this
application or within two years following the date of marriage. If that
two-year period has expired, this application is your last
opportunity to elect a survivor benefit for your present spouse.
If you were not married to your current spouse on your 62nd birthday,
you may elect an annuity with less than the full survivor benefit or with
no survivor benefit (or in most cases with survivor benefit to former
spouse, if that marriage terminated, or your 62nd birthday occurred, on
or after May 7, 1985), without the consent of, or notice to, your current
spouse or any prior spouse. If a former spouse has a court order, dated
on or after May 7, 1985, which properly awards him or her a survivor
annuity, the Office of Personnel Management (OPM) will honor the
court order.
Waiver of Spousal Consent Requirement
The spousal consent requirement may be waived if you show that your
spouse's whereabouts cannot be determined. A request for waiver on this
basis must be made in writing and accompanied by:
-
A judicial determination that your spouse's whereabouts cannot be
determined; OR
-
Affidavits by you and two other persons, at least one of whom is not
related to you, attesting to the inability to locate the current spouse and
stating the efforts made to locate the spouse. You must also give
documentary evidence, such as tax returns filed separately or newspaper
stories about the spouse's disappearance.
The spouse's consent requirement may also be waived if you present a
judicial determination regarding the current spouse that would warrant
waiver of the consent requirement based on exceptional circumstances.
(Illness or injury of the retiree is not justification for waiving the spousal
consent requirement.)
Court-Ordered Former Spouse Annuities
OPM must honor a court order/divorce decree on or after May 7, 1985, that
gives (awards or requires you to provide) a survivor annuity to a former
spouse. OPM cannot honor court-order modifications issued after the
retirement involving a former spouse survivor annuity. Your annuity will
be reduced to provide the survivor annuity for the former spouse. However,
a former spouse cannot receive a survivor annuity by a court order unless:
1. He or she was married to you for at least 9 months;
2. You have at least 18 months of service subject to retirement deductions;
3. He or she has not remarried before reaching age 55; and
4. The marriage ended on or after May 7, 1985.
If you are married and a court order has awarded a survivor annuity to your
former spouse, see the section Electing a Survivor Annuity for a Current
Spouse When a Court Order Gives a Survivor Annuity to Former Spouse
on page 4. This explains how you can protect your current spouse's future
survivor annuity rights.
Electing a Survivor Annuity For a Former Spouse or a
Combination of Survivor Annuities for Current and Former
Spouses
If your marriage ended on or after May 7, 1985, you may elect a reduced
annuity to provide a maximum (55% of your unreduced annuity) or
less-than-maximum survivor annuity for a former spouse (or spouses).
1. To make a former spouse annuity election, you must have been married
to the person for a total of at least 9 months and you must have at least
18 months of service that was subject to retirement deductions. A
former spouse who marries again before reaching age 55 is not eligible
for a former spouse survivor annuity.
2.
You may elect to provide a survivor annuity for more than one former
spouse. If you are married, you may elect a survivor annuity for your
current spouse as well as a survivor annuity for one or more former
spouses. However, the total of the survivor annuities may not exceed
55% of your unreduced annuity.
Page 3
OPM Form 1496
Revised October 2002
3. To elect a reduced annuity to provide a survivor annuity for a
former spouse or a combination of survivor annuities for current
and former spouse(s), complete and attach OPM 1496, Schedule A,
Election of Former Spouse Survivor Annuity or Combination
Current/Former Spouse Annuity.
Electing a Survivor Annuity for a Current Spouse When a
Court Order Gives a Survivor Annuity to a Former Spouse
1. If a court order has given a survivor annuity to a former spouse, you
must make your election concerning a survivor annuity for your
current spouse as if there were no court-ordered former spouse
annuity. By electing the maximum survivor benefits for your
current spouse at retirement, you can protect your spouse's
rights in case your former spouse loses entitlement in the future
(because of remarriage before age 55, under the terms of the court
order, or death). You can do this because the Civil Service
Retirement System (CSRS) must honor the terms of the court order
and you are not required to ELECT a survivor annuity for the
former spouse. (Note: The election you make now regarding a
survivor annuity for your current spouse cannot be changed
except as explained in the section titled "Annuity Election
Changes After Retirement.") The following paragraphs explain in
more detail how your election at the time of retirement can affect
your current spouse's future rights if the court has given a survivor
annuity to a former spouse.
2.
If a court order gives a survivor annuity to a former spouse, your
annuity will be reduced to provide it. If you elect a full or partial
survivor annuity for your current spouse (or another former spouse),
your annuity will be reduced no more than it would be to provide a
survivor annuity equal to 55% of your unreduced annuity.
3.
If you die before your current and former spouse, the total amount
of the survivor annuities paid cannot exceed 55% of your annuity,
and the CSRS must honor the terms of the court order before it can
honor your election. The former spouse having the court-ordered
survivor benefit would receive an annuity according to the terms of
the court order.
4.
If a court order gives the maximum survivor annuity to the former
spouse, your widow(er) would receive no survivor annuity until the
former spouse loses entitlement. Then your widow(er) would
receive a survivor annuity according to your election.
5.
If the court order gives less than the maximum survivor annuity to
the former spouse, your widow(er) would receive an annuity no
greater than the difference between the court-ordered survivor
annuity and 55% of your annuity. However, if the former spouse
loses entitlement to the survivor annuity (through remarriage before
age 55, under the terms of the court order, or death), your
widow(er)'s survivor annuity would be increased to the amount you
elected.
For example, if there is a court-ordered former spouse survivor
annuity that equals 40% of your annuity, you elect the maximum
survivor annuity for your current spouse, and you die before the
former spouse's entitlement to a survivor annuity ends, the former
spouse would receive a survivor annuity equal to 40% of your
annuity and your widow(er) would receive a survivor annuity equal
to 15% of your annuity.
However, if the former spouse later loses entitlement to the survivor
annuity (through remarriage before age 55, under the terms of the court
order, or death), your widow(er) would then receive a survivor annuity
equal to 55% of your annuity.
Electing an Insurable Interest Annuity For a Current Spouse
See the discussion on page 2 of these instructions for the definition of
Insurable Interest.
1. If a former spouse's court-ordered survivor annuity will prevent your
current spouse from receiving a survivor annuity that is sufficient to
meet his or her anticipated needs, you may want to elect an insurable
interest annuity for your current spouse.
2.
If you elect an insurable interest survivor annuity for your current
spouse, you and your current spouse must jointly waive the regular
survivor annuity. To accomplish this:
a. initial box 1B in Section C of the OPM Form 1496, and write
"none" in the space following that box (i.e., election to provide no
regular survivor annuity);
b. complete Section C, item 4 naming your current spouse (i.e.,
election to provide insurable interest benefit);
c. complete Part 1, item b of OPM Form 1496, Schedule B;
d. have Parts 2 and 3 of Schedule B completed (i.e., spouse's consent
to insurable interest benefit in lieu of regular survivor annuity).
3. If you elect an insurable interest survivor annuity for your current
spouse and your former spouse loses entitlement before you die, you
may request that the reduction in your annuity to provide the insurable
interest annuity be converted to the regular spouse survivor annuity;
this would result in a larger annuity. (See Annuity Election Changes
After Retirement.) Your current spouse would then be entitled to the
regular survivor annuity. In addition, if your former spouse loses
entitlement after you die, your widow(er) can ask the Office of
Personnel Management (OPM) to substitute the regular survivor
annuity for the insurable interest survivor annuity.
4.
If for any reason OPM cannot allow your insurable interest election for
your current spouse, your current spouse will be considered elected for
a maximum regular survivor annuity unless your current spouse signs
another form consenting to less than a maximum regular survivor
annuity or OPM approves a waiver of consent.
Annuity Election Changes After Retirement
1. Subject to the consent requirement, you may name a new survivor or
change your election if, not later than 30 days after the date of your
first regular monthly payment, you file a new election in writing. If the
person you named to receive a survivor annuity dies or your current
marriage ends through death, divorce or annulment, you should write
OPM immediately if you want to change your election. Your first
regular monthly payment is the first annuity check payable on a
recurring basis after OPM has initially adjudicated the regular rate of
annuity payable under CSRS and has paid the annuity accrued since
the time of retirement.
Page 4
OPM Form 1496
Revised October 2002
2. When the 30-day period following the date of your first regular
monthly payment has passed, you cannot change your election except
under the circumstances explained in the following paragraphs.
3. You may change your decision not to provide a survivor annuity for
your spouse at retirement or you may increase the survivor annuity
amount you elected for your spouse at retirement if you request the
change in writing no later than eighteen months after the
commencing date of your annuity, and if you pay a deposit
representing the difference between the reduction for the new
survivor election and the original survivor election, plus a charge of
$245.00 per each thousand-dollar change in the designated survivor
base. (Interest on the deposit must also be paid.) Such an election
would cancel any joint waivers made at retirement. However, the
total survivor annuity(ies) provided for former spouses (by court
order or election) and the current spouse cannot exceed 55% of your
annuity. You may not change your election to provide a lesser
survivor benefit for your spouse, except as discussed in item 1 above.
4.
The reduction in your annuity to provide a survivor annuity for your
current spouse stops if your marriage ends because of death, divorce,
or annulment. However, you may elect, within two years after the
marriage ends, to continue the reduction to provide a former spouse
survivor annuity for that person, subject to the restrictions in
paragraph 10. If you marry someone else before you make this
election, your new spouse must consent to your election.
5.
The reduction in your annuity to provide a survivor annuity for a
former spouse ends: (1) when the former spouse dies, (2) when the
former spouse remarries before reaching age 55, or (3) under the
terms of the court order that required you to provide the survivor
annuity for the former spouse when you retired. (Modifications of the
court order issued after you retire do not affect the former spouse
annuity.) However, if at retirement you had elected a survivor
annuity for your current spouse (or another former spouse), the
reduction will be continued to provide the survivor annuity for that
person. If you have not previously made an election regarding a
current spouse whom you married after retirement (or if your election
regarding a current spouse at retirement was based on a waiver of
spousal consent), you may, within two years after the former spouse
loses the right to a survivor annuity, elect a reduced annuity to
provide a survivor annuity for that current spouse. This election is
subject to the restrictions given in paragraph 10.
6.
If you were unmarried at retirement, you may elect, within two years
after a post-retirement marriage, a reduced annuity to provide a
maximum or less-than-maximum survivor annuity for your spouse,
subject to the restrictions given in paragraph 10. Your annuity will
be reduced no earlier than nine months after the date of your
marriage.
7.
If you were married at retirement, that marriage ends, and you marry
again, you may elect, within two years after the remarriage, a reduced
annuity to provide a survivor annuity for your new spouse, subject to
the restrictions given in paragraph 10. (However, if you remarry the
same person you were married to at retirement and that person had
previously consented to your election of no survivor annuity, you
may not elect to provide a survivor annuity for that person when you
remarry.) Your annuity will be reduced no earlier than nine months
after the date of your marriage.
8. If, at retirement, you received (by election or court order) a reduced
annuity to provide a survivor annuity for a former spouse and you
elected to provide an insurable interest survivor annuity for your
current spouse, you may change the insurable interest election to a
regular current spouse survivor annuity within two years after your
former spouse loses entitlement (because of remarriage before age 55,
the terms of the court order or death), subject to restrictions a and b
given in paragraph 10.
9.
The reduction in your annuity to provide an insurable interest annuity
ends if the person you named to receive the insurable interest annuity
dies or when the person you named is your current spouse and you
change your election as explained in paragraph 8. The reduction also
ends if, after you retire, you marry the insurable interest beneficiary
and elect to provide a regular survivor annuity for that person. If you
marry someone other than the insurable interest beneficiary after you
retire and elect to provide a regular survivor annuity for your new
spouse, you may elect to cancel the insurable interest reduction.
10.
Post-retirement survivor elections are subject to the following
restrictions:
a.
They cannot be honored to the extent that they conflict with
the terms of a court order that requires you to provide a
survivor annuity for a former spouse;
b.
They cannot be honored if they cause combined current and
former spouse survivor annuities to exceed 55% of your
unreduced annuity; and
c.
If, during any period after you retired, your annuity was not
reduced to provide a current or former spouse survivor
annuity, you must pay into the retirement fund an amount
equal to the amount your annuity would have been reduced
during that period plus 6% annual interest.
11. Insurable interest elections are not available after retirement.
Section D - Federal Service
The letter attached to this package includes a list of your Federal and Postal
service presently included in your retirement record. If you have any
additional civilian Federal or Postal service, before or after the date of final
separation, list it in the spaces provided. Attach additional sheets of paper if
more space is needed. Attach a copy of any available documentation you
may have to verify the additional service claimed. Documentation which
may be useful in verifying service includes notices of appointment,
separation or salary change. The Office of Personnel Management will
attempt to locate official records to verify your claim even if you cannot
supply documentation. If we are unable to do so, we will let you know.
Information you give will help us to assure proper credit for all service.
Federal service is service as an employee of the United States Government.
Generally, to be considered an employee of the United States Government
for civil service retirement purposes, a person must be:
a. engaged in the performance of Federal functions under the
authority of an act of Congress or an Executive Order,
b. appointed in the Civil Service by a Federal officer, and
c. under the supervision and direction of a Federal officer.
Page 5
OPM Form 1496
Revised October 2002
Section E - Military Service
Military service can be added to your civilian Federal service under
the circumstances outlined below:
Item 1: If you have performed active duty that terminated under
honorable conditions in the armed services or other uniformed services
of the United States, enter, for each period of active duty, (a) the
branch of service (Army, Navy, etc.), (b) your serial number for that
period of service, (c) the beginning and ending dates of active duty,
(d) your last grade or rank during that period of service, and (e) your
organization (company, division, etc.) at discharge. If available, attach
a copy of your discharge certificate or other documentation of the
active military service.
Active military service, generally rendered on a full-time basis with
military pay and allowances, includes the following:
a. Army, Navy, Marine Corps, Air Force or Coast Guard of the
United States.
b. Cadet or Midshipman of the United States Military Academy,
United States Air Force Academy, United States Coast Guard
Academy, or United States Naval Academy.
Service in reserve components and/or the National Guard is not
considered active Federal military service except when ordered to
active duty in the service of the Unites States and during an initial
training period.
Information about your active duty military service is needed so that
we can compare your claim with other records and request verification
of all claimed military service. This assures that you are credited with
the correct amount of active military service.
Item 2: Indicate whether or not you are receiving or have applied for
military retired pay.
If you are receiving military retired pay, your military service cannot
be used for civil service retirement purposes, unless:
a.
Your final separation was before April 1, 1948, and military
retired pay was based on disability, or under Chapter 67, Title
10 (formerly Title III, Public Law 80-810), or
b.
Your final separation was on/after April 1, 1948, and
on/before September 30, 1956, and military retired pay was
either on account of disability incurred in combat with an
enemy of the United States or which resulted from an explosion
of an instrumentality of war, or under Chapter 67, Title 10,
(formerly Title III, Public Law 80-810).
If you are receiving military retired pay, the conditions in a or b above
do not apply to you, and you wish to combine your military and
civilian service to compute your civil service annuity, you must waive
your military retired pay.
In order to waive military retired pay you should send a written
request, specifying the effective date of the waiver and your social
security number, directly to the Military Finance Center from which
you receive retired pay. Preferably this should be at least 60 days
before the commencing date of your civil service annuity (your 62nd
birthday). Your letter might say, "I, (full name, military serial number,
and social security number), hereby waive my military retired pay for
civil service retirement purposes, effective close of business (the day
before annuity commences)." If you wish, add "I authorize the Office
of Personnel Management to withhold from my civil service retirement
annuity any amount of military pay granted beyond the effective date of this
waiver due to any delay in receiving or processing this election." This
authorization may hasten the processing of your waiver and your retirement
application.
If you have already waived military retired pay in order to receive credit for
active duty military service for civil service retirement purposes, attach a
copy of your request for waiver and of any reply you have received.
Section F - Other Claims Information
Item 1: Indicate whether or not you have ever applied for retirement,
refund, deposit or redeposit, or voluntary contributions, under the Civil
Service Retirement System. If you have, indicate which in 1a and the
applicable claim numbers in 1b. This helps to assure that all of your records
are located and that proper credit is given for your service, and for any
deposit, redeposit, or voluntary contribution payments you have made.
Item 2: Indicate whether or not you have ever been employed under
another retirement system for Federal or District of Columbia employees. If
your answer is "yes," fill in the name of that retirement system in 2a and the
dates of services in 2b. This helps to assure proper consideration is given to
all of your service. The service you show here cannot be used to compute
your civil service annuity if the other retirement system is paying you
retirement based on the service.
Item 3: If you have applied for, or received, workers' compensation from
the Office of Workers' Compensation Programs, U.S. Department of Labor,
because of a job-related illness or injury sustained during Federal
employment, check the "yes" box and furnish your claim numbers and dates
of benefits in 3a and 3b.
The information requested regarding benefits from the Office of Workers'
Compensation Programs is needed because the law prohibits payment of
both civil service retirement annuity and compensation for total or partial
disability under the Federal Employees' Compensation Act at the same time.
In some cases, credit for service, particularly for periods of leave without
pay, may also be affected.
Section G - Certification of Applicant
Be sure to sign (do not print) and date your application, after reviewing the
warning.
FILING YOUR APPLICATION
Send your completed application, and any attachments requested in the
instructions or the letter, to Office of Personnel Management, Civil Service
Retirement System, Retirement Operations Center, Boyers, Pennsylvania,
16017.
WHAT HAPPENS AFTER YOU FILE YOUR APPLICATION
1.
The Office of Personnel Management will acknowledge receipt of your
application and give you an identification card. This card will give you
your claim number, which will begin with the letters "CSA." This
number will be very important to you as an annuitant, because you will
need to refer to it any time you write or call us in connection with your
annuity.
2.
We will search our files for all records and previous claims related to
your Federal service and place these with your application in your CSA
claim file.
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OPM Form 1496
Revised October 2002
3. We will determine if any additional information is needed to
adjudicate your claim and obtain it. For example, we may need to
obtain official records of service claimed by you but not recorded
in our files, certification of your military retired pay status, etc.
We can obtain most of this information from other Federal
agencies; we will let you know if any additional information is
needed from you. Finally, we will compute the amount of your
annuity.
4.
When we finish processing your application, we will send you a
(or payments sent to your bank) by the U.S. Department of the
booklet explaining your benefits. Checks will be mailed to you
Treasury.
WHAT TO DO IF YOUR ADDRESS CHANGES
BEFORE PROCESSING IS COMPLETED
If your address changes before you receive your acknowledgment and
identification card, write us over your personal signature, giving your
name, date of birth, social security number, and your new address. If
you have received your acknowledgment, remember to refer to your
claim number. In addition, you should promptly notify your old Post
Office of your forwarding address.
HOW TO HAVE YOUR ANNUITY PAYMENT SENT
TO A BANK OR FINANCIAL INSTITUTION
To have your annuity payments sent directly to a bank or financial
organization, contact us or complete Standard Form 1199A, Direct
Deposit Sign-Up Form. This form is available only from your bank or
financial organization. To complete it you will need the Civil Service
Annuity claim number we give you when we acknowledge receipt of
your application.
Having your annuity payments sent directly to your bank or financial
organization is both convenient and safe, and eliminates the possibility
of lost or stolen checks. It also assures that payments are deposited and
available for your use, even when you are away from home.
Informational material continues to be sent to your correspondence
address.
COST-OF-LIVING INCREASES
Cost-of-Living increases are effective on December 1 and are payable
in the January annuity payment. They are determined by the
percentage increase in the average Consumer Price Index for the "base
quarter" of the year in which they are effective over the "base quarter"
of the preceding year. The "base quarter" is July, August, and
September. The first cost-of-living increase you receive will be
prorated to reflect the number of months you are on the retirement
rolls before the increase is effective.
AMOUNT OF ANNUITY
The Office of Personnel Management will compute your annuity. See
Annuity Computation for more information.
LENGTH OF SERVICE
Add up the years, months and days of all your periods of Federal service,
including creditable military service, before your final separation from
civilian service covered by the retirement act. The total years and months
constitute your length of service. Any days left over, that don't make a full
month, are dropped.
If redeposit is not made for service which ended before October 1, 1990,
and your annuity commences on or after December 2, 1990, you will
receive credit for the period of service covered by the refund in your
annuity computation. However, if you do not pay the redeposit for this
service, your annuity will be permanently, actuarially reduced. You will be
given an opportunity to pay the redeposit.
AVERAGE PAY
Your "high-5" average pay, which is the highest average annual pay
produced by your basic pay rates during any 5 consecutive years of service,
each rate weighed by length of time it was in effect, is used in the
computation of your annuity. In most cases, the last five years of service
give the highest average pay, but any 5 consecutive years may be used.
Within-grade periodic pay increases are part of basic pay, but additional pay
such as overtime is not.
ANNUITY COMPUTATION
Separation between January 24, 1942, and March 31, 1948
You can estimate the amount of your annuity by first multiplying $30.00 by
your years of creditable service; then adding $8.00 for each $100.00 in your
retirement account. For example, if you had 12 years' service and $1,000 in
your retirement account, your basic annuity would be roughly ($30 x 12) +
$80, or $440 a year.
Separation on/after April 1, 1948 and before October 1, 1956
If your average pay (the average annual basic pay for the highest 5
consecutive years of your service) is less than $5,000, your basic annuity
will be 1% of your average pay, plus $25.00, multiplied by your total years
of service. If your average pay is $5,000 or more, your basic annuity will be
1-1/2% of your average pay, multiplied by your total years of creditable
service.
In no case may basic annuity exceed 80% of average pay.
If deductions were not withheld during creditable service on/after August 1,
1920, your basic annuity will be reduced by 10% of the unpaid deposit (the
amount of deductions plus interest) unless deposit is paid before
adjudication is completed. (This type of service is called noncontributory
service.)
Increase based on separation before October 20, 1969
Annuities based on final separation before October 20, 1969, are increased
by $20.00 per month beginning on the commencing date of annuity or
August 1, 1974, whichever is later.
Reduction for Survivor Annuity
This reduction is explained under INSTRUCTIONS FOR COMPLETING
APPLICATION, Section C, Annuity Election. Unmarried children under
age 18 are usually eligible for survivor annuity after your death. This
eligibility does not depend on the type of annuity you elect and does not
reduce the amount of your annuity.
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OPM Form 1496
Revised October 2002
ADDITIONAL ANNUITY
An employee who, in addition to the amounts withheld from salary,
has made voluntary contributions to the Retirement Fund will be paid,
in addition to the regular annuity, $7.00 plus $0.20 for each full year
the individual is over age 55 at retirement, for each $100.00 in his or
her voluntary contributions account. If an employee elects a voluntary
contributions survivor annuity, the additional annuity purchased will
be reduced based on the difference between the annuitant's age and the
survivor's age. The survivor's additional annuity is 50% of the
employee's additional reduced annuity.
Privacy Act Statement
Solicitation of this information is authorized by the Civil Service
Retirement law (Chapter 83, title 5, U.S. Code). The information you
furnish will be used to identify records properly associated with your
application for Federal benefits, to obtain additional information if
necessary, to determine and allow present or future benefits, and to
maintain a unique identifiable claim file for you. The information may be
shared and is subject to verification, via paper, electronic media, or through
the use of computer matching programs, with national, state, local or other
charitable or social security administrative agencies in order to determine
benefits under their programs, to obtain information necessary under this
program, or to report income for tax purposes. It may also be shared with
law enforcement agencies when they are investigating a violation or
potential violation of civil or criminal law. Public law 104-134 (April 26,
1996) requires that any person doing business with the Federal government
furnish a social security number or tax identification number. This is an
amendment to title 31, Section 7701. Failure to furnish the requested
information may delay or make it impossible for us to determine your
eligibility for benefits.
PAYMENT AND ACCRUAL OF ANNUITY
All annuities are payable in monthly installments on the first business
day of the month following the one for which the annuity has accrued.
Monthly annuity rates are rounded down to the next lower dollar. This
provision also applies to annuities that were redetermined and to
cost-of-living adjustments.
IF YOU NEED HELP TO COMPLETE THIS
APPLICATION -
* Write to:
Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045
Public Burden Statement
We think this form takes an average 60 minutes per response to complete,
including the time for reviewing instructions, getting the needed data, and
reviewing the completed form. Send comments regarding our estimate or
any other aspect of this form, including suggestions for reducing
completion time, to the Office of Personnel Management, OPM Forms
Officer (3206-0121), Washington, DC 20415-7900. The OMB Number,
3206-0121 is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.
You may call our Retirement Information Office toll-free at
1-888-767-6738 Monday through Friday from 7:30 a.m. to 7:45 p.m.
That office is closed on Federal holidays. If you are calling within the
local Washington, DC, area, dial 202-606-0500. Callers who use TDD
equipment should call 1-800-878-5707 or within the local calling area
202-606-0551.
We also provide retirement brochures, forms, and other information on
the Internet at http://www.opm.gov/retire and respond to email sent to
retire@opm.gov.
Page 8
OPM Form 1496
Revised October 2002
Civil Service Retirement System
Form Approved
OMB No. 3206-0121
APPLICATION FOR DEFERRED RETIREMENT
(For Persons Separated Before October 1, 1956)
Please read the Instructions carefully before you complete this application.
Section A - Identifying Information
1. Name (last, first, middle)
2. List all other names you have used
3. Address (number, street, city, state, ZIP code)
4. Telephone number
(including area code)
5. Date of birth
(mm/dd/yyyy)
6. Social Security Number
7. Are you a citizen of the United States of America?
Yes
No - If "No," give
7a. Name of country of which you are a citizen
Section B - Marital Information
1. Are you married now? (A marriage exists until ended by death, divorce or annulment.)
Yes (also complete items 1a - 1f below)
No
1a. Spouse's name (last, first, middle)
1b. Spouse's date of
birth (mm/dd/yyyy)
1c. Spouse's Social
Security Number
1d. Place of marriage (city, state) 1e. Date of marriage
(mm/dd/yyyy)
1f. Marriage performed by
Clergyman or Justice of the Peace
Other (explain):
STATEMENT REGARDING FORMER SPOUSES
All applicants must complete this statement if their annuities commence on or after May 7,
1985.
2. Do you have a living former spouse(s) whose marriage to you
ended by divorce or annulment on or after May 7, 1985, and to
whom a court order gives a survivor annuity?
Yes - Attach a certified copy of the court order(s) and any amendments.
No
Section C - Annuity Election
Make your election by initialing the box beside the type of annuity
you want to receive and give any other information requested.
Consider your election carefully. No change will be permitted after
your annuity is finally granted except as explained in the
instructions. If you are currently married and you do not elect
maximum survivor benefits, the law requires that your spouse
consent to your election as discussed in the attached instructions, you
must complete OPM Form 1496, Schedule B and attach it to this
application.
1. I choose a reduced annuity with survivor annuity for my
spouse equal to:
INITIALS
A) 55% OF ALL MY ANNUITY
OR
INITIALS
B) 55% OF $_______________ A YEAR
This amount must be less than your
yearly annuity.
2. I choose a self-only annuity.
INITIALS
All retiring former employees may
choose this type of annuity
3. I choose a reduced annuity to provide a former spouse
or combination current/former spouse survivor annuity.
The attached Schedule A gives my election.
INITIALS
4. I choose a reduced annuity with a survivor annuity
for the person named below who has an insurable
interest in me.
INITIALS
You must be healthy and willing to
undergo a physical examination if you
choose this type of annuity.
Name of person with insurable interest Relationship to
you
Date of birth
(mm/dd/yyyy)
Social Security Number
U.S. Office of Personnel Management OPM Form 1496
Previous editions are not usable Revised October 2002
(445) 454-5464
Section D - Federal Service
List below any Federal (or Postal) service you have performed that is NOT included in the list of your service on the form notifying you of your
eligibility for deferred retirement. Attach any documentation you may have to prove your claim to additional service.
Dept. or agency, including bureau or division Location (city and state)
Dates of service
From (mm/dd/yyyy) To (mm/dd/yyyy)
Section E - Military Service
1. If you have performed active, honorable service in the Armed Services or other uniformed services of the United States (see instructions for
definition), complete items 1a-1e below and attach a copy of your discharge certificate or other certificate of active military service (if available).
1a. Branch of service 1b. Serial number
1c. Dates of active duty
From (mm/dd/yyyy) To (mm/dd/yyyy)
1d. Last grade or
rank
1e. Organization at discharge
(Div., Co., etc.)
2. If you are receiving or have applied for military retired pay (including disability retired pay), complete items 2a-2d below.
2a. Are you receiving or have you ever applied for military retired or
retainer pay? (Answer "yes" if you are receiving payments from the
Department of Veterans Affairs instead of military retired pay.)
Yes
No
2b. Was your military retired or retainer pay awarded for disability
incurred in combat or caused by an instrumentality of war?
(If available, attach a
copy of notice of
Yes
award)
No
2c. Was your military retired or retainer pay awarded for reserve service
under Chapter 67, title 10? [Now Chapter 1223, title 10]
(If available, attach a copy of
Yes notice of award) No
2d. Are you waiving your military retired pay in order to receive
credit for military service for Civil Service Retirement Benefits?
(See instructions for information about how to
request a waiver and its effect on your annuity.
Yes
Attach a copy of your waiver request to this form.)
No
Section F - Other Claims Information
1. Have you previously filed any application under the Civil Service
Retirement System (for retirement, refund, deposit, or voluntary
contributions)?
Yes
(also complete items 1a and 1b below)
No
1a. Type of application
Retirement
Deposit or redeposit
Refund
Voluntary contributions
1b. Claim number(s)
2. Have you ever been employed under another retirement system for
Federal or District of Columbia employees?
Yes
(also complete items 2a and 2b below)
No
2a. Name of other retirement system 2b. Dates of service
From (mm/dd/yyyy) To (mm/dd/yyyy)
3. Have you ever received compensation under the Federal Employees
Compensation Act?
Yes
(also complete items 3a, 3b and 3c below)
No
3a. Compensation claim no. 3b. Description of benefit
Scheduled award
Total or partial disability compensation
3c. Dates benefits received
From (mm/dd/yyyy) To (mm/dd/yyyy)
Section G - Applicant's Certification
WARNING
Any intentionally false or willfully misleading statement, certification,
or response you provide in this application is a violation of the law
punishable by a fine of not more than $10,000 or imprisonment of
not more than 5 years, or both (18 U.S.C. 1001)
I hereby certify that all statements made in this application are true to the best of my
knowledge and belief. I have read and understand all of the information provided in the
instructions to this application.
Signature (do not print) Date (mm/dd/yyyy)
U.S. Office of Personnel Management OPM Form 1496
Previous edition
s are not usable
Revised October 2002
Election of Former Spouse Survivor Annuity
or Combination Current/Former Spouse Annuity
If you were age 62 before May 7, 1985, and your marriage ended before May 7, 1985, you are not eligible to elect a survivor annuity for
that former spouse.
Identification of Applicant
Name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
If your former spouse was awarded a survivor annuity by court decree or order, your annuity will be reduced to provide that
benefit. You do not need to elect a survivor annuity for that former spouse.
Election: I elect a reduced annuity to provide a survivor annuity or survivor annuities for my current/former spouse(s)
as follows:
Name and address of current/former spouse Date of marriage
(mm/dd/yyyy)
Date of divorce*
(mm/dd/yyyy)
Survivor annuity
equal to
%
of my annuity
Date of birth (mm/dd/yyyy) Social Security Number
Name and address of former spouse Date of marriage
(mm/dd/yyyy)
Date of divorce
(mm/dd/yyyy)
Survivor annuity
equal to
%
of my annuity
Date of birth (mm/dd/yyyy) Social Security Number
Name and address of former spouse Date of marriage
(mm/dd/yyyy)
Date of divorce
(mm/dd/yyyy)
Survivor annuity
equal to
%
of my annuity
Date of birth (mm/dd/yyyy) Social Security Number
Total (cannot exceed 55% of your unreduced annuity)
%
Signature Date (mm/dd/yyyy)
* If current spouse, enter "Not Applicable."
Information: You may elect a reduced annuity to provide a full (55% of your annuity) or partial (less than 55% of your annuity) survivor annuity for a
former spouse, if you were married to that person for at least nine months and you have at least 18 months of Federal service that was subject to civil service
retirement deductions. A former spouse who marries before age 55 is not eligible for a survivor annuity.
If you are married and elect to provide a partial survivor annuity for a former spouse:
You may also elect to provide a partial survivor annuity for your current spouse and/or former spouse(s). However, the sum of
all survivor annuities cannot exceed 55% of your unreduced annuity.
Your current spouse must consent using OPM Form 1496, Schedule B, to any election that does not provide him or her with
a full survivor annuity.
If you are not married, you may elect partial survivor annuities for one or more former spouses. However, the sum of all survivor annuities cannot exceed
55% of your unreduced annuity.
To elect a former spouse annuity, do not mark either box in item 1 of Section C of the OPM Form 1496. Instead, mark item 3. Then complete and attach this
OPM Form 1496 Schedule A, which allows you to elect a benefit for a former spouse or to divide the benefit between your current spouse and former
spouse(s).
Documents you must attach:
1. Copies of divorce decrees for all former spouses for whom you elect to provide a survivor annuity.
2. If you are married, you must also attach a completed OPM Form 1496, Schedule B, Spouse's Consent to Survivor Annuity Election.
OPM Form 1496, Schedule A U.S. Office of Personnel Management
Previous editions are not usable Revised October 2002
0
SPOUSE'S CONSENT TO SURVIVOR ELECTION
(For retirements commencing on or after May 7, 1985, under the Civil Service Retirement System)
Instructions: If you are married and do not elect a reduced annuity to provide a full current spouse survivor annuity, complete Part 1. If you mark item a,
fill in the blank to show the amount of your annuity that you entered on OPM Form 1496, Section C. Have your spouse complete Part 2. Part 2 must be
completed in the presence of a Notary Public or other person authorized to administer oaths. The Notary Public must complete Part 3.
Part 1 - To be completed by the applicant
Name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
I have elected: (Mark the one box which describes the election you have made with regard to your current spouse.)
a. A partial survivor annuity for my current spouse equal to:
(1) 55% of $____________________ a year. (This agrees with my election in Section C, item 1B, on my completed OPM Form 1496.)
(2) ____________________ % of my annuity. (This agrees with my completed OPM Form 1496, Schedule A.)
b. No regular survivor annuity for current spouse, but I am electing an insurable interest survivor annuity for my current
spouse. (I have completed Section C, item 4, on my OPM Form 1496, naming my current spouse.)
c. No regular or insurable interest survivor annuity for my current spouse.
Part 2 - To be completed by current spouse of applicant
I freely consent to the survivor election described in Part 1. I understand that my consent is final (not revocable).
Name (type or print) Signature (do not print) Date (mm/dd/yyyy)
Part 3 - To be completed by Notary Public or other person authorized to take acknowledgements
I certify that the person named in Part 2 presented identification (or was known to me), gave consent, signed or marked this form, and acknowledges that
the consent was freely given in my presence on this
the _______________ day of _________________, __________, at _____________________________________________________________.
(month) (year) (city and state)
(SEAL)
Signature
Expiration date of commission, if Notary Public
General Information: Based on Public Law 98-615, a married applicant whose annuity begins on or after May 7, 1985, receives a fully reduced annuity
to provide a maximum survivor annuity for his or her spouse, unless the retiree and the spouse consent to a less than full survivor annuity by signing this
form or the Office of Personnel Management (OPM) approves a waiver of the spouse consent.
A court order which requires an applicant to provide a survivor annuity for a former spouse is not an election, and spousal consent is not required. In
other words, such a court order does not require a current spouse to waive the right to a survivor annuity. The applicant can still elect to provide a
survivor annuity for the current spouse even though OPM must honor the terms of the court order before it can honor the election for the current spouse.
The current spouse may, therefore, receive a smaller annuity than elected, or none at all, unless the former spouse loses eligibility for the court-ordered
survivor annuity (through remarriage before age 55, under the terms of the court order, or death).
Important: If the current spouse consents to an election to provide no survivor annuity or a partial survivor annuity and is later divorced from the retiree,
the retiree may not then elect (nor can OPM honor a court order) to provide a former spouse survivor annuity which exceeds the amount elected at
retirement for that spouse.
Privacy Act Statement
Public Law 98-615, which establishes the spousal consent requirement, authorizes solicitation of this information. The data furnished will be used to determine the type of annuity awarded. The
information may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social
security administrative agencies to determine and issue benefits under their programs. It may also be shared and verified, as noted above, with law enforcement agencies when they are
investigating a violation or potential violation of the civil or criminal law. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a
social security number or tax identification number. This is an amendment to title 31, Section 7701. Failure to furnish the requested information may delay or prevent action on the retirement
application.
OPM Form 1496, Schedule B
U.S. Office of Personnel Management
Previous editions are not usable Revised October 2002
0
SPOUSE'S NOTIFICATION OF SURVIVOR ELECTION
(For retirements commencing on or after January 1, 1981, and before May 7, 1985, under the Civil Service Retirement System)
If you are married, you will receive a reduced annuity with survivor
annuity payable to your spouse in the event of your death, unless
you elect otherwise. Therefore, you may choose:
a)
The maximum survivor annuity which provides the surviving
spouse an annuity of 55% of your annuity.
b)
Less than the maximum survivor annuity, providing the
surviving spouse an annuity of 55% of a smaller portion of
your annuity.
c)
No survivor annuity to the surviving spouse.
Public Law 96-391 requires that if you elect less than the maximum
survivor annuity, all reasonable attempts must be made to notify your
spouse.
Complete Part 1 of this form and have your spouse complete Part 2.
Your spouse's signature must be witnessed by two people in Part 3. You
may not be a witness.
If you cannot obtain your spouse's signature, complete Part 4. The
Office of Personnel Management will attempt to notify your spouse as
required by law.
Submit the completed Schedule C with your application.
Part 1 - To be completed by the applicant
Name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number
On my retirement application, I have elected
(Mark "x" in appropriate box)
Less than the maximum survivor annuity.
No survivor annuity for my spouse.
Part 2 - To be completed by the spouse of the applicant
I am aware of the survivor election made by my spouse as shown in Part 1, above.
Signature (do not print) Date signed (mm/dd/yyyy)
Part 3 - To be completed by witnesses
We, the undersigned, certify that this form was signed by the spouse of the applicant in our presence.
Signature (do not print)
Date signed
(mm/dd/yyyy)
Name of witness (type or print)
Address (number and street)
(city, state and ZIP code)
Signature (do not print)
Date signed
(mm/dd/yyyy)
Name of witness (type or print)
Address (number and street)
(city, state and ZIP code)
Part 4 - To be completed by the applicant, if the spouse's signature is unobtainable
Name and last known mailing address of spouse
Privacy Act Statement
Public Law 96-391, which establishes spouse notification requirements, authorizes solicitation
of this information. The data furnished will be used to determine the type of annuity awarded.
This information may be shared, and is subject to verification, via paper, electronic media, or
through the use of computer matching programs, with national, state, local or other charitable
or social security administrative agencies to determine and issue benefits under their programs.
It may also be shared and verified, as noted above, with law enforcement agencies when they
are investigating a violation or potential violation of civil or criminal law.
Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal
government furnish a Social Security Number or tax identification number. This is an
amendment to title 31, Section 7701. Failure to furnish the requested information may result in
your receiving an annuity with full reduction for the maximum survivor benefit.
U.S. Office of Personnel Management
OPM Form 1496, Schedule C
Previous editions are not usable
Revised October 2002
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Completed 1 November 2019

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