United States
Office of Personnel Management
Request for Offset for Health Benefits Premiums
From Monies Payable Under the Civil Service Retirement System (CSRS)
or the Federal Employees Retirement System (FERS)
(In Lieu of Standard Form 2805)
Office of Personnel Management
Retirement Operations Center
Boyers, PA 16017
The former employee named below is indebted to the United States (under § 890.502(b) of title 5, Code
of Federal Regulations) for health benefits premiums. To liquidate this indebtedness, we request that
you set off the gross amount of the debt as shown below, against the former employee's account in the
Civil Service Retirement and Disability Fund. The former employee's retirement record (Standard Form
2806 or Standard Form 3100) is is not attached.
Name of office designated by the employing agency to receive evidence of the liquidation of the debt.
Street address
City, state, and ZIP code
Retirement system
FERS CSRS
Social Security Number
From To
$
Date
(typed or printed) Telephone number(typed or printed)
Payroll office number
Each period of non-pay status
for which offset is required
Name of former employee
Date of birth Date of termination of service
Amount of debt for each period Total amount of debt
Location of employment (city, state)
Appropriation or fund (title and symbol number) Disbursing office (name and symbol number)
I certify that this debt is properly due the United States, and that before making this request, we notified
this individual that OPM will make the collection from any CSRS or FERS benefits payable. A copy of
the former employee's signed consent is attached.
Signature of certifying official
Name of certifying official (including area code) Title of certifying official
OPM 1522
Revised June 2006
Previous edition is not usable.
