Agency Certification
I certify that the above information accurately describes the agency's offer of position to the applicant, if such offer was made, and that
documentation required in Chapter 44 of CSRS and FERS Handbook for Personnel and Payroll Offices is attached.
3. The offered position must be in the employee's agency, includ-
ing an agency to which the employee is transferred with
his/her function in a transfer of function between agencies.
1. Applicant's name
(last, first, middle)
1. The agency offer of the position must be in writing.
17. Typed name and title of responsible agency personnel
officer
5. Was the employee given a written offer of a position in your agency (or in another agency to which his or her function was
transferred in a transfer of function between agencies)?
Yes: Also complete items 6-13 below. No: Skip to Agency Certification, items 14-18.
Certification of Agency Offer of Position and Required Documentation
(for Discontinued Service Retirement Under CSRS or FERS)
Instructions to Agency Personnel
Complete this certification whenever an employee is being separated for discontinued service retirement. Attach the completed form
to the employee's application for retirement. If a properly completed certification does not accompany an employee's retirement
application, OPM will not authorize any annuity payments, including interim payments, until the certification is received, unless the
employee is also eligible for retirement based on his or her age and service. A job offer is a "reasonable offer" if all of the following
conditions are met.
4. The offered position must be within the employee's
commuting area, unless the employee is under a geographic
mobility agreement.
2. The employee must meet established qualification
requirements for the position.
5. The offered position must be of the same tenure as the current
position.
6. The offered position must not be lower than the equivalent of
2 grade/pay levels below the employee's current grade or pay
level.
Certification
2. Date of birth
(month, day, year)
3. Social Security Number
4. Is the employee in the Senior Executive Service?
Yes If "Yes", is the discontinued service retirement eligibility based on:
No
Failure to be recertified?
Less than fully successful performance?
Other
(explain)
6. Give employee's current job title, classification series and grade. 7. Give the offered position's job title, classification series and
grade.
8. The offered position was
(check the appropriate box)
:
Within the Outside the
commuting area commuting area
9. Was a geographic mobility agreement in effect for the
employee?
Yes No
10. Was the offered position of the same work schedule
(full-time
for full-time employee; part time of at least the same number of
hours for part-time employee, etc.)
?
Yes No
11. Was the offered position of the same tenure, i.e., in the same
service
(competitive, excepted, or Senior Executive Service)
and of
the same type
(career, permanent, indefinite, etc.)
?
Yes No
12. Does the employee meet the X-118 or equivalent qualifications
of the offered position?
Yes No
13. Was the grade or pay level of the offered position within two
grades or pay levels of the employee's position?
Yes No
14. Signature of responsible agency personnel officer 15. Telephone number 16. Date
18. Name and mailing address of agency
