Fillable Opm1496a Printing C:\OPM149~1.FRP

Fill Online, Printable, Fillable, Blank Opm1496a Printing C:\OPM149~1.FRP Form

Use Fill to complete blank online U.S. OFFICE OF PERSONNEL MANAGEMENT (GA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Opm1496a Printing C:\OPM149~1.FRP

On average this form takes 39 minutes to complete

The Opm1496a Printing C:\OPM149~1.FRP form is 21 pages long and contains:

  • 0 signatures
  • 57 check-boxes
  • 128 other fields

Country of origin: US
File type: PDF

U.S.A. forms for U.S. Office of Personnel Management

BROWSE U.S. OFFICE OF PERSONNEL MANAGEMENT (GA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form Approved
United States
OMB No. 3206-0121
Office of Personnel Management
Retirement Operations Center
Boyers PA 16017
Date of birth (mm/dd/yyyy)
Date of separation giving eligibility (mm/dd/yyyy)
Commencing date of annuity (mm/dd/yyyy)
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 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.
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:
Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045
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:
Retirement Operations
OPM Form 1496A
Prior editions are not usable
Revised March 2012
Application For Deferred Retirement
Civil Service Retirement System (CSRS)
(Separations on or after 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
System (CSRS) 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. You had at least 5 years of creditable civilian Federal
service at the time of your final separation from a position
subject to CSRS.
2. You were covered by CSRS for at least 1 year out of the last
2 years preceding the final separation on which entitlement
is based.
3. You have not drawn a refund of retirement deductions
covering your final period of service.
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: Type or print your name clearly.
Item 2: 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.
Item 3: Enter your Social Security Number. The Treasury
Department requires us to report, by Social
Security Number, the amount paid to each
annuitant.
Item 4: 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
6 for information about how to do this.)
Item 5: Give a telephone number where you can be reached
in case more information is needed.
Item 6: 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 7: Provide your email address.
Item 8: 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.
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.
OPM Form 1496A
Revised March 2012
Page 1
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 below 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 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
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 survivor annuity through death or
remarriage prior to reaching age 55. The 9-month 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.
OPM Form 1496A
Revised March 2012
Page 2
Notice to Applicants Who Married After Age 62
Since you were not married to your current spouse at age 62 (the
commencing date of your deferred annuity), you do not need
your spouse's consent to your annuity election in Section C.
Please refer to Annuity Election Changes After Retirement,
item 6, for detailed information.
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 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 following section
Electing a Survivor Annuity for a Current Spouse When a Court
Order Gives a Survivor Annuity to a Former Spouse. 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.
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 Form
1496A, 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.
OPM Form 1496A
* The maximum is 50% if you separated from Federal service before
Revised March 2012
October 11, 1962.
Page 3
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 1496A, 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 1496A, 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 must inform OPM
immediately . Your first regular monthly payment is the first
annuity payable on a recurring basis after OPM has initially
determined the regular rate of annuity payable under CSRS
and has paid the annuity accrued since you reached age 62.
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 new survivor election
and the original survivor election, plus a charge of $245.00
for 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.) If
you and your former spouse were married for 30 years or
longer, the reduction does not end. 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.
OPM Form 1496A
Revised March 2012
* The maximum is 50% if you separated from Federal service before October 11, 1962.
Page 4
6. If you were not married 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. Please note that the pre-divorce survivor
annuity election automatically terminates upon divorce. You
must make a new election within two years after the divorce to
provide a survivor annuity for a former spouse. Continuing a
survivor reduction, by itself, is not a former spouse survivor
election. (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 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
your 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.
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 at the U.S. Military Academy, U.S. Air Force
Academy, U.S. Coast Guard Academy, or Midshipman
at the U.S. Naval Academy.
c. Regular Corps or Reserve Corps of the Public Health
Service after June 30, 1960.
d.
Commissioned Officer of the National Oceanic and
Atmospheric Administration after June 30, 1961.
e.
Active service in the reserve components of the
uniformed services, including active duty for training,
is military service. Service as a National Guard member
does not meet the definition of military service for
purposes of civil service retirement, except when the
member is ordered to active duty in the service of the
United States or performs full-time National Guard
duty (as such term is defined in section 101(d) of title
10) if the National Guard duty interrupts creditable
civilian service under subchapter III of chapter 83 of
title 5, and is followed by reemployment in accordance
with chapter 43 of title 38 that occurs on or after
August 1, 1990.
OPM Form 1496A
Revised March 2012
* The maximum is 50% if you separated from Federal service before October 11, 1962.
Page 5
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 in a civilian position subject to CSRS
coverage, 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 a civilian position subject to
CSRS coverage before October 1, 1982, and
a. 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.
b. 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 the
Office of Personnel Management (OPM).
2. If you were first employed in a civilian position subject to
CSRS coverage 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.
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 1223, title 10, U.S. Code, Sections 12731 through
12739, formerly chapter 67, title 10 (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.
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 - Direct Deposit/Direct Express
The U.S. Department of the Treasury pays all federal benefits
electronically. Your payments can be made by Direct Deposit to
your checking or savings account or you need to arrange for a
Direct Express debit card provided by the Department of the
Treasury. To enroll in the Direct Deposit program, contact your
financial institution or OPM. To obtain a debit card, go to
www.godirect.org. If your payments are not electronically
deposited to your account and you do not have a Direct Express
card, you must contact the Department of the Treasury at
1-800-333-1795 to discuss your options. This does not apply if
your permanent payment address is outside the United States in a
country not accessible via Direct Deposit/Direct Express.
OPM Form 1496A
Revised March 2012
Page 6
Use Section G, item 3 to give OPM instructions regarding
Federal income tax withholding. If you do not give any
instructions, the Internal Revenue Service has instructed OPM to
withhold at the rate for a married person with three exemptions.
Contact OPM at any time to change the amount of tax withheld.
After your application is processed, you will be able to instruct
OPM to withhold State income tax, provided your State
participates in OPM's State Tax Withholding Program.
Section H - 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 a Retirement
Reference Card showing the claim number assigned to
your application. The claim numbers begin with the letters
"CSA." This number is very important to you; you will
need to refer to it any time you contact 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.
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 booklet explaining your benefits and any monthly survivor
benefits. This booklet contains information you will need,
including how to contact OPM to make various changes (tax
withholding, address, change in marital status, etc.)
What To Do If Your Address Changes Before
Processing Is Completed
If your address changes, call us using the numbers on page 8 or
write us over your personal signature, giving your name, date of
birth, social security number, and your new address. Remember to
refer to your claim number. If you write to us, report your new
address to:
U.S. Office of Personnel Management
Attn: Change of Address
P.O. Box 440
Boyers, PA 16017-0440
In addition, you should notify the Postal Service of your
forwarding address.
Cost-of-Living Increases
1. 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.
2. 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.
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.
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 19, 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 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.
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.
OPM Form 1496A
Revised March 2012
Page 7
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 rate by 12 and
round down. Annuities based on final separations before October
20, 1969, are increased by $20.00 per month.
Reduction for Refunded Service
Civilian service for which retirement deductions were withheld
from your salary and later refunded to you is called "refunded"
service. A "redeposit" is a payment to the retirement fund to cover
a period of refunded service. Generally, you do not have to make a
redeposit if you do not wish to do so. However, this can affect the
amount of your monthly annuity.
If redeposit is not made for refunded service which ended on
or after March 1, 1991, you will receive no credit in the
computation of your annuity for the period of refunded service.
This usually results in a reduction in the amount of your annuity,
or, in the event of your death, your eligible widow's (or widower's)
annuity. The period of service will be creditable for title and
average salary purposes whether or not a redeposit is made.
If redeposit is not made for refunded service which ended
before March 1, 1991, and if you separated from service on or
after October 28, 2009, you will receive credit in your annuity
computation for the period of refunded service. If you do not pay
the redeposit for this service, full credit for the refunded service
will be allowed in computing your annuity, but the annuity will be
permanently actuarially reduced based on your age and the amount
of redeposit, including interest, you owe at age 62. You can elect
to pay the redeposit and avoid the actuarial reduction.
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.
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.
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 you do 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. If you have such service, you will
be given an opportunity to pay the deposit with interest before we
complete our action on your application.
Reduction for Survivor Annuity
This reduction is explained under Instructions for Completing
Application, Section C, Annuity Election on page 1.
Unmarried children under 18, disabled children over 18, and
student children under age 22 may be 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.
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, $8.40 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. Note: The additional annuity is not increased by
cost-of-living adjustments.
If you have not already done so, you may request a refund of your
voluntary contributions. However, interest on refunded voluntary
contributions does not accrue after the date you separated from
your Federal employment.
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:
U.S. Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045
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. 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 www.opm.gov/retire and respond to
email sent to retire@opm.gov.
OPM Form 1496A
Revised March 2012
Page 8
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 civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of
the Social Security Number. Furnishing the data requested is voluntary. Failure to furnish the requested information may delay or make it
impossible for us to determine your eligibility for benefits.
Public Burden Statement
We estimate 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, Retirement Services Publications Team (3206-0121),
Washington, D.C. 20415-3430. 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.
OPM Form 1496A
Revised March 2012
Page 9
Form Approved
Civil Service Retirement System
OMB No. 3206-0121
Application For Deferred Retirement
Civil Service
(For persons separated on or after October 1, 1956)
Retirement System
Please read the Instructions carefully before you complete this application.
Section A - Identifying Information
1. Name (last, first, middle) 2. List all other names used 3. Social Security Number
4. Address (number, street, city, state, ZIP code)
5. Telephone number (including area code) 6. Date of birth (mm/dd/yyyy)
7. Email address
8. Are you a citizen of the United States of America?
Yes No - If "No," give
8a. 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 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.
Initials
A)
55% of all my annuity
(Separation on or after 10/11/62)
50% of all my annuity
1. I choose a reduced annuity with survivor annuity for my spouse
OR
(Separation before 10/11/62)
equal to:
55% of ________________ * a year B)
50% of ________________ * a year
Initials
(Separation on or after 10/11/62)
(Separation before 10/11/62)
Initials
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. Note: This election is not included in
determining the 55% maximum for the combined
benefit elected for a spouse and former spouse in
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.
(If you are married and elect this, complete and attach Schedule B.)
2. I choose a self-only annuity.
(If you are married and elect this, complete and attach Schedule B.)
4. 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.)
box 5.
Name of person with insurable interest Relationship to you Date of birth (mm/dd/yyyy) Social Security Number
* This amount must be less than your yearly annuity.
U.S. Office of Personnel Management
OPM Form 1496A
Previous editions are not usable
Revised March 2012
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
Dates of service
From (mm/dd/yyyy) To (mm/dd/yyyy)
Location (city and state)
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).
Serial number
From (mm/dd/yyyy) To (mm/dd/yyyy)
Branch of service 1b.
Dates of active duty
1d. Last grade or rank 1e.
2. If you are receiving or have applied for military retired pay (including disability retired pay), complete items 2a-2d below.
1a. 1c. Organization at discharge
(Div., Co., etc.)
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?
Yes (If available, attach a copy of notice
of award)
No
2c. Was your military retired or retainer pay awarded for reserve service under
Chapter 1223, title 10? [Formerly Chapter 67, Title 10]
Yes (If available,
attach a copy of
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?
Yes (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.)
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
Refund
Deposit or redeposit
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 number 3b. Description of benefit
Scheduled award
Total or partial disability
3c. Dates benefits received
From (mm/dd/yyyy) To (mm/dd/yyyy)
U.S. Office of Personnel Management
OPM Form 1496A
Previous editions are not usable
Revised March 2012
Section G - Direct Deposit/Direct Express And Tax Withholding Information
1. Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department
of the Treasury. For additional information, see page 6 of the instructions for completing this form. This does not apply to you if your permanent payment address is
outside the United States in a country not accessible via Direct Deposit. Please select one of the following:
Please send my annuity payments to my checking or savings account. (Go to item 2)
Please send my annuity payments to my Direct Express debit card. (Go to Section H)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to Section H)
Checking
Savings
2b. Account number
2a. Financial institution routing number
2. Please provide information about your financial institution below.
2c. Name and address of financial institution 2d. Telephone number of
your financial institution
(including area code)
Yes
3. Do you want Federal income tax withheld from your annuity payments? (See Section G discussion on page 6 and 7 of the instructions.)
No
Section H - Applicant's Certification
Warning
I hereby certify that all statements made in this application are true to the best of my
Any intentionally false or willfully misleading statement,
knowledge and belief. I have read and understand all of the information provided in the
certification, or response you provide in this application is a
instructions to this application.
violation of the law punishable by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both
Signature (do not print) Date (mm/dd/yyyy)
(18 U.S.C. 1001)
OPM Form 1496A
Revised March 2012
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
Total (cannot exceed 55% of your unreduced annuity)**
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:
%
Survivor annuity
equal to
of my annuity
Name and address of current/former spouse Date of marriage (mm/dd/yyyy) Date of divorce* (mm/dd/yyyy)
Date of birth (mm/dd/yyyy) Social Security Number
Name and address of former spouse
%
Survivor annuity
equal to
of my annuity
Date of marriage (mm/dd/yyyy) Date of divorce (mm/dd/yyyy)
Date of birth (mm/dd/yyyy) Social Security Number
Name and address of former spouse
%
Survivor annuity
equal to
of my annuity
Date of marriage (mm/dd/yyyy) Date of divorce (mm/dd/yyyy)
Date of birth (mm/dd/yyyy) Social Security Number
%
Signature Date (mm/dd/yyyy)
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.
* If current spouse, enter "Not Applicable."
** The maximum is 50% if you separated from Federal service before October 11, 1962.
U.S. Office of Personnel Management
Previous editions are not usable
OPM Form 1496A, Schedule A
Revised March 2012
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 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.
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 1496A.)
(2) __________ % of my annuity. (This agrees with my completed OPM Form 1496A, Schedule A.)
b. No regular survivor annuity for my 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.
d.
A survivor annuity for my former spouse__________________________________________ equal to _______% of my annuity.
(name of former 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 acknowledgments
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)
Signature
(Seal)
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 applicant 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 spousal 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 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 civil or criminal law. Executive Order 9397 (November 22,
1943) authorizes the use of the Social Security Number. Failure to furnish the requested information may delay or prevent action on the retirement application.
U.S. Office of Personnel Management OPM Form 1496A, Schedule B
Previous editions are not usable Revised March 2012
PRINT
SAVE
CLEAR
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Opm1496a Printing C:OPM1491.FRP

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 November 2019

Message

View Audit Log
Print With Audit Log
Duplicate Document