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Opm1496a (U.S. Office of Personnel Management)

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Civil Service Retirement deductions were:
UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
OFFICE OF RETIREMENT PROGRAMS
BOYERS, PA 16017
Form Approved
OMB No. 3206-0121
Records on file with the Office of Personnel Management 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
the Office of Personnel Management. See the enclosed information.
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.
YOU MAY BE ELIGIBLE FOR DEFERRED RETIREMENT
Remarks:
Keep the instructions (pages 1 thru 9) 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
Boyers, PA 16017
Prior editions are not usable.
Retirement Operations Center
Revised March 1998
OPM Form 1496A
Department or Agency and Location
Date of birth
Date of separation giving eligibility
Commencing date of annuity
Beginning
Date
Ending
Date
Civil Service Retirement Deductions were:
Not Withheld Refunded
Withheld
TO APPLICATION
OPM Form 1496A
Revised March 1998
Item 6:
Item 7:
Section B - Marital Information
Item 1:
Item 1a:
Item 1b:
Item 1c:
Item 1d:
Item 1e:
Item 1f:
Item 2:
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 2.
Box 1A: Maximum Survivor Benefit
If you initial Box 1A, you are electing the maximum survivor benefit.
Final Separation on or after October 11, 1962
If you initial Box 1A, 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.
APPLICATION FOR DEFERRED RETIREMENT
(Separations on or after October 1, 1956)
INTRODUCTION
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.
Enter your social security number. The Treasury
Department requires us to report, by social security
number, the amount paid to each annuitant.
Indicate your citizenship.
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.
Enter your spouse's name.
Enter your spouse's date of birth (month-day-year).
Furnish your spouse's social security number.
Enter the place of your marriage (town or city and state).
Enter the date of your marriage (month-day-year).
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.
Indicate whether you have a living former spouse whose
marriage to you ended by divorce or annulment on or after
May 7, 1985. If you answer "yes," you must submit a copy
of the court order and any attachments or amendmen
ts.
Page 1
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 on or after 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
You are eligible for a deferred annuity if:
1.
2.
3.
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. A deferred annuity commences on your
62nd birthday, no matter when you apply for it. 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.
INSTRUCTIONS FOR COMPLETING APPLICATION FOR
DEFERRED ANNUITY
Section A - Identifying Information
Item 1:
Item 2:
Item 3:
Item 4:
Item 5:
Type or print your name clearly.
List other names under which you have been
employed in the Federal government (such as maiden
name). This will make it possible for us to locate and
identify records maintained under such names.
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.)
Give a telephone number where you can be reached
in case more information is needed.
Give your date of birth, showing the month, then the
day, then the year. Your retirement records are filed
You had at least 5 years of creditable civilian Federal service
at the time of your final separation from a position subject to
the Civil Service Retirement law.
You were covered by the Civil Service Retirement law for at
least 1 year out of the last 2 years preceding the final
separation on which entitlement is based.
You have not drawn a refund of retirement deductions
covering your final period of service.
OPM Form 1496A
Revised March 1998
Final Separation before October 11, 1962
If you initial Box 1A, your spouse's survivor annuity upon your
death will be 50% of ALL your annuity. Your annuity will be
reduced by 2-1/2% of the first $2,400 and 10% of the remainder
of your annual annuity to provide this benefit.
Box 1B: Less than Maximum Survivor Benefit
If you initial Box 1B, you must complete and attach OPM Form
1496A, 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 below for exceptions to the consent
requirements.)
Final Separation on or after October 11, 1962
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
.
Final Separation before October 11, 1962
If you initial Box 1B, your spouse's survivor annuity upon your
death will be 50% 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
$2,400 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 1496A, 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
below 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 1496A, 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 1496A, Schedule B,
Spouse's Consent to Survivor Election, if you are married and
initial Box 3. (See Important Information About Annuity
Election on this page 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, if final separation was before October 11, 1962; 55% if
final separation was on or after October 11, 1962.
Age of Person Named Reduction in
in Relation to That of Annuity of
Retiring Employee 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.
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 1496A, 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 not attached.
Page 2
OPM Form 1496A
Revised March 1998
* The maximum is 50% if you separated from Federal service before
October 11, 1962.
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
Page 3
Notice to Applicants Whose 62nd Birthday Was Before May 7,
1985
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--
Use the attached Schedule C if you need to notify your spouse that
you are electing less than the maximum survivor annuity.
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, 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:
-
-
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 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.
2.
3.
4.
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 a 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.
2.
3.
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.
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.
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 Form 1496A, Schedule A, Election of Former
Spouse Survivor Annuity or Combination Current/Former
Spouse Annuity.
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.
He or she was married to you for at least 9 months;
You have at least 18 months of service subject to
retirement deductions;
He or she has not remarried before reaching age 55; and
The marriage ended on or after May 7, 1985.
OPM Form 1496A
Revised March 1998
Electing a Survivor Annuity for a Current Spouse When a
Court Order Gives a Survivor Annuity to a Former Spouse
1.
2.
3.
4.
5.
* The maximum is 50% if you separated from Federal service before
October 11, 1962.
Page 4
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.
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.
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.
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.
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
Annuity Election Changes After Retirement
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.
2.
3.
4.
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.
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.
b.
c.
d.
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.
)
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 OPM to substitute the
regular survivor annuity for the insurable interest survivor
annuity.
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.
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.
initial box 1B in Section C of the OPM Form 1496A, and
write "none" in the space following that box (i.e., election
to provide no regular survivor annuity);
complete Section C, item 4 naming your current spouse
(i.e., election to provide insurable interest benefit);
complete Part 1, item b of OPM Form 1496A, Schedule B;
have Parts 2 and 3 of Schedule B completed (i.e., spouse's
consent to insurable interest benefit in lieu of regular
survivor annuity).
8.
9.
10. Post-retirement survivor elections are subject to the following
restrictions:
a.
b.
c.
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 records. If you
have performed 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.
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;
They cannot be honored if they cause combined current and
former spouse survivor annuities to exceed 55%* of your
unreduced annuity; and
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.
OPM Form 1496A
Revised March 1998
2.
3.
4.
5.
6.
7.
Page 5
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.
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 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.
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.
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.
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.
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.
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.
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.
* The maximum is 50% if you separated from Federal service before
October 11, 1962.
a.
b.
2.
Item 2:
Indicate whether or not you are receiving or have applied
for military retired pay. (Military retired pay includes disability
pay.)
If you are receiving military retired pay, your military service
cannot be used for civil service retirement purposes, unless such
retired pay was awarded on account of a service-connected
disability incurred in combat or caused by an instrumentality of
war in the line of duty during a war period, or was awarded under
Chapter 67, title 10, formerly title III of Public Law 80-810
(reserve retired pay at age 60 based on 20 years of active and
reserve service). If you are receiving military retired pay and 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 done 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.
OPM Form 1496A
Revised March 1998
If you were first employed in the Federal service on or after
October 1, 1982, you must have paid the deposit for
post-1956 military service in order to receive credit for that
service for retirement purposes. In other words, unless you
paid the deposit, we will not allow credit for post-1956
military service at the time your annuity commences,
regardless of whether you are or will become eligible for
social security benefits.
If you were separated from the Federal service before
October 1, 1982, we will allow credit for military service
after 1956 until you are eligible for social security. Then,
we will offset the amount of your civil service benefit that is
attributable to your post-1956 military service by any
amount of social security benefit that is also attributable to
that service. The law does not provide for you to pay a
deposit. If you are able to send us information and
documentation concerning your eligibility for social
security benefits, it may help us to process your application
more quickly.
If you separated from the Federal service on or after
October 1, 1982, you had the option of paying a deposit for
post-1956 military service in order to avoid any reduction
that would otherwise take effect when you became eligible
for social security benefits. An exception to the rule that the
deposit must be paid while the individual is still employed
exists for individuals whose final separation from Federal
employment occurred between October 1, 1982, and
October 1, 1983. These persons may pay the deposit
directly to OPM.
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.
b.
c.
d.
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. Merchant Marine service is not creditable
as military service.
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.
Deposit for Military Service
Persons who performed active duty military service after
December 31, 1956, may have paid a deposit to avoid an annuity
reduction. Read the following discussion to determine which
category describes your service. The deposit is 7% of the military
basic pay you received, plus interest at a variable rate determined
each year by the U.S. Treasury Department. Interest is charged if
the deposit is paid after October 1, 1986, or three years after you
were first employed, whichever is later. If you did not pay your
deposit while you were still Federally employed, you cannot pay
it now, unless your final separation occurred as stated in 1.b.
below.
1. If you were first employed in the Federal service before
October 1, 1982, and
Page 6
Army, Navy, Marine Corps, Air Force or Coast Guard of
the Unites States.
Cadet or Midshipman of the United States Military
Academy, United States Air Force Academy, United
States Coast Guard Academy, or United States Naval
Academy.
Regular Corps or Reserve Corps of the Public Health
Service after June 30, 1960.
Commissioned Officer of the National Oceanic and
Atmospheric Administration (formerly Coast and Geodetic
Survey and Environmental Science Services
Administration) after June 30, 1961.
4.
Checks will be mailed to you (or payments sent to your bank) by the
U.S. Department of the Treasury.
WHAT TO DO IF YOUR ADDRESS CHANGES
BEFORE PROCESSING IS COMPLETED
The acknowledgment we will send you will include a change of
address form. If your address changes before you receive your
acknowledgment, 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, you must 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
1.
2.
OPM Form 1496A
Revised March 1998
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 service 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.
2.
3.
Page 7
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.
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.
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.
When we finish processing your application, we will send you a
package containing:
a.
b.
Your annuity statement; and
A booklet containing general information about your
annuity.
Limitation on amount of increase
An annuity may not be increased by a cost-of-living adjustment
to an amount that exceeds the greater of (a) the maximum pay
payable for a GS-15 thirty days before the effective date of the
adjustment or (b) the final pay (or average pay, if higher) of the
retired employee, increased by the overall annual average
percentage adjustments (compounded) in General Schedule rates
of pay since the employee's retirement.
Determination of amount of increase and effective date.
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.
the computation of your annuity if your final separation was on or
after October 20, 1969.
ANNUITY COMPUTATION
The amount of your annuity is a percentage of your average pay
(see left). The percentage is determined by a three-part formula
based on your length of creditable service. Credit is given for whole
months only, defined as 30 days. You earn:
1.50% per year for the first 5 years, or 7.50%, and
1.75% per year for the next five years, or 8.75%, and
2.00% per year for service over ten years.
Thus, after ten years of service you have earned 16.25% [7.50% +
8.75%] of your average pay. After 8 years and 3 months of service
you have earned 13.19% of your average pay [7.50% + (1.75% X
3.25) = 13.19%]. To give another example, after 15 years and 6
months of service you have earned 27.25% of your average pay
[16.25% + (2% X 5.5) = 27.25%].
If your average pay is less than $5,000, you may substitute 1% of
your average pay plus $25 for the percentages in any or all parts of
the formula if it increases your basic annuity.
The result of the computation is your basic annuity, which must be
reduced for any or all of the applicable reasons described in the
following sections, to produce your yearly annuity rate. To find
your monthly payment amount, divide your yearly annuity rate. To
find your monthly payment amount, divide your yearly rate by 12
and round down. Annuities based on final separations before
October 20, 1969, are increased by $20.00 per month.
Reduction for Non-Deduction Service
If you have creditable service performed before October 1, 1982,
during which no retirement deductions were made from salary and
for which deposit has not been made in the retirement fund, your
basic annuity will be reduced by 10% of the unpaid deposit. The
unpaid deposit consists of the amount which would have been
withheld as retirement deductions, plus interest. This reduction does
not apply, and no deposit need be made for military service
performed before January 1, 1957. If an applicant does not make a
deposit for civilian service performed on or after October 1, 1982,
for which no retirement deductions were made, the service cannot
be used in computing the annuity.
Reduction for Survivor Annuity
This reduction is explained under
Instructions for Completing
Application, Section C, Annuity Election
on page 1.
Unmarried children under 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.
OPM Form 1496A
Revised March 1998
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 you performed service for which you have been paid a refund
of retirement deductions, you may redeposit the refund, with
interest, to increase the amount of your annuity.
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.
If redeposit is not made for service which ended on or after
October 1, 1990,
any such period of service for which you have
been paid a refund of retirement deductions cannot be included in
your length of service unless you redeposit the refund.
In either event, we will send you information about the amount of
redeposit and its effects on your annuity and will give you an
opportunity to pay the redeposit.
If you have performed creditable service on or after October 1,
1982, during which no retirement deductions were withheld and
for which you have not paid a deposit, you will be given an
opportunity to pay the deposit, with interest.
AVERAGE PAY
Final Separation from September 30, 1956, to October 19,
1969
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 weighted by length of time it was in
effect, is used in the computation of your annuity. In most cases,
the last 5 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.
Final Separation from October 20, 1969, to the Present
Your "high-3" average pay, computed as described in the
previous paragraph but using 3 years instead of 5, is used in
Page 8
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.
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
Boyers, PA 16017
OPM Form 1496A
Revised March 1998
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 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 the civil or criminal law. Public law 104-134
(April 26, 1996) requires the 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.
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), Reports and Forms Manager,
Paperwork Reduction Project (3206-0121), Washington, D.C. 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.
Page 9
•
B) 55% OF * A YEAR
(Separation on or after 10/11/62)
50% OF * A YEAR
(Separation before 10/11/62)
All applicants must complete this statement if their annuities commence on or after
May 7, 1985.
4.
3.
INITIALS
Yes - Attach a copy of the court order(s) and any amendments.
No
Section C - Annuity Election
I choose a reduced annuity with a survivor annuity
for the person named below who has an insurable
interest in me. (You may initial this box and also boxes 1 or 3 above.)
Date of birth (mo, day,
yr)
Relationship to
you
1.
2.
I choose a reduced annuity to provide a former
spouse or combination current/former spouse
survivor annuity. The attached Schedule A gives my
election.
=
==
=(If you are married and elect this, also attach Schedule B or C.)
I choose a self-only annuity
(If you are married and elect this, complete and attach Schedule B or C.)
INITIALS
Yes
No - If "No," give
APPLICATION FOR DEFERRED RETIREMENT
Civil Service Retirement System
(For persons separated on or after October 1, 1956)
Please read the Instructions carefully before you complete this application.
Section A - Identifying Information
Section B - Marital Information
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 attached
instructions. If you are currently married and you do not elect
maximum survivor benefits, the law requires that your spouse
consent to your election. Therefore you must complete OPM Form
1496A, Schedule B and attach it to this application. Exception: If you
were 62 on or after January 1, 1981, and before May 7, 1985, attach
Schedule C instead of Schedule B.
I choose a reduced annuity with survivor annuity for my
spouse equal to:
7. Are you a citizen of the United States of America? 7a. Name of country of which you are a citizen
1. Are you married now? (A marriage exists until ended by death, divorce or annulment.)
Yes
(also complete items 1a - 1f below)
No
1b. Spouse's date of
birth (mo, day, yr)
1c. Spouse's social
security number
1e. Date of Marriage
(mo, day, yr)
1d. Place of Marriage (city, state)
5. Date of Birth (mo,
day, yr)
6. Social Security Number3. Address (number, street, city, state, ZIP code)
4. Telephone number
(including area
code)
1. Name (last, first, middle)
2. List all other names you have used
1a. Spouse's Name
(last, first, middle)
55% OF ALL MY ANNUITY
A) (Separation on or after 10/11/62)
50% OF ALL MY ANNUITY
(Separation before 10/11/62)
Form Approved
OMB No. 3206-0121
* This amount must be less than your yearly annuity.
U.S. Office of Personnel Management
Previous editions are not usable
INITIALS
STATEMENT REGARDING FORMER SPOUSES
2. Do you have a living former spouse(s) whose marriage to you
ended by divorce or annulment on or after May 7, 1985?
OR
INITIALS
INITIALS
All retiring former employees may
choose this type of annuity
You must be healthy and willing to
undergo a physical examination if you
choose this type of annuity.
Name of person with insurable interest Social security number
OPM Form 1496A
Revised March 1998
FormFlow 2.15
1f. Marriage performed by
Other (explain):
Clergyman or Justice of the Peace
Dates of service
Scheduled award
Total or partial disability
Section G - Applicant's Certification
Section E - Military 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.
2. If you are receiving or have applied for military retired pay (including disability pay), complete items 2a-2d below.
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).
Section D - Federal Service
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)
Date
U.S. Office of Personnel Management
Previous editions are not usable
2a. Are you receiving or have you ever applied for military
retired or retainer pay?
2c. Was your military retired or retainer pay awarded for reserve service
under Chapter 67, title 10?
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)?
2b. Was your military retired or retainer pay awarded for disability
incurred in combat or caused by an instrumentality of war?
2d. Are you waiving your military retired pay in order to receive
credit for military service for Civil Service Retirement Benefits?
(If available, attach a
copy of notice of
award)
(See instructions for information about how to
request a waiver and its effect on your annuity.
Attach a copy of your waiver request to this form.)
Yes No
Yes No
(If available, attach a copy of
notice of award)
Yes
No
(also complete items 1a and 1b below)
1a. Type of application 1b. Claim number(s)
2. Have you ever been employed under another retirement system for
Federal or District of Columbia employees?
2a. Name of other retirement system
2b. Dates of service
From (mo, day, yr) To (mo, day, yr)
3. Have you ever received compensation under the Federal Employees
Compensation Act?
3c. Dates benefits received
From (mo, day, yr) To (mo, day, yr)
3a. Compensation claim no.
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)
Retirement
Refund
Yes
No
(also complete items 2a and 2b below)
Yes
No
(also complete items 3a, 3b and 3c below)
WARNING
Yes
Yes
Deposit or redeposit
Voluntary contributions
No
No
3b. Description of benefit
OPM Form 1496A
Revised March 1998
1a. Branch of service 1b. Serial number
1c. Dates of active duty
1d. Last grade or
rank
From (mo,day,yr) To (mo,day,yr)
1e. Organization at discharge
(Div., Co., etc.)
From (mo,day,yr) To (mo,day,yr)
Dept. or agency, including bureau or division Location (city and state)
* 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 1496A, 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 1496A. Instead, mark item 3. Then complete and attach
this OPM Form 1496A Schedule A, which allows you to elect a benefit for a former spouse or 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 1496A, Schedule B, Spouse's Consent to Survivor Annuity Election.
U.S. Office of Personnel Management
Previous editions are not usable
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
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:
* The maximum is 50% if you separated from Federal service before October 11, 1962.
Name and address of current/former spouse
Name and address of former spouse
Name and address of former spouse
Date of marriage
Date of birth
Date of marriage
Date of birth
Date of marriage
Date of birth
Date of divorce*
Social security number
Date of divorce
Social security number
Date of divorce
Social security number
%
%
%
%
Total (cannot exceed 55% of your unreduced annuity)
Signature Date
Name
(last, first, middle)
Date of Birth
(month,day,year) Social security number
Survivor annuity
equal to
Survivor annuity
equal to
Survivor annuity
equal to
of my annuity
of my annuity
of my annuity
OPM Form 1496A, Schedule A
Revised March 1998
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)
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 1496A.)
(2) % of my annuity. (This agrees with my completed OPM Form 1496A, 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 1496A, naming my current spouse.)
c. No regular or insurable interest survivor annuity for my current spouse.
Date
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 1496A, 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.
Expiration date of commission, if Notary Public
Name (type or print)
U.S. Office of Personnel Management
Previous editions are not usable
SPOUSE'S CONSENT TO SURVIVOR ELECTION
(For retirements commencing on or after May 7, 1985, under the Civil Service Retirement System)
Name (last, first, middle) Date of birth
(month,day,year) Social security number
(SEAL)
Signature
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 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 the Office of Personnel Management (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 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 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
I freely consent to the survivor election described in Part 1. I understand that my consent is final (not revocable).
Signature
(do not print)
OPM Form 1496A, Schedule B
Revised March 1998
Part 1 - To be completed by the applicant
Part 2 - To be completed by current spouse of applicant
Part 3 - To be completed by Notary Public or other person authorized to administer oaths
Part 1 - To be completed by the applicant
Part 3 - To be completed by witnesses
Part 4 - To be completed by the applicant, if the spouse's signature is unobtainable
I am aware of the survivor election made by my spouse as shown in Part 1, above.
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:
The maximum survivor annuity which provides the surviving
spouse an annuity of 55%* of your annuity.
Less than the maximum survivor annuity, providing the
surviving spouse an annuity of 55%* of a smaller portion of
your annuity.
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.
* The maximum is 50% if you separated from Federal service before
October 11, 1962.
Part 2 - To be completed by the spouse of the applicant
Signature (do not print) Date signed (mo, day, yr)
Name (last, first, middle) Date of birth (mo, day, yr) 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.
We, the undersigned, certify that this form was signed by the spouse of the applicant in our presence.
Signature (do not print) Signature (do not print)
Name of witness (type or print)
Address (number and street)
(city, state and ZIP code) (city, state and ZIP code)
Address (number and street)
Name of witness (type or print)
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
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 result
in your receiving an annuity with full reduction for the maximum survivor benefit.
U.S. Office of Personnel Management
Previous editions are not usable
Date signed
(mo, day, yr)
Date signed
(mo, day, yr)
OPM Form 1496A, Schedule C
Revised March 1998
a)
b)
c)
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Completed 26 July 2020

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