Form Approved
Supplemental Semiannual Headcount Report
OMB No. 3206-0262
1. Address of Payroll Office (including department, bureau,
location and zip code)
2. Payroll Office Number 3. Report Number
4. Date Payroll Paid
5. Pay Period
From To
6. To 7. Name of Preparer (print) 8. Telephone Number
Office of Personnel Management
ATTN: Funds Management
P.O. Box 582
Washington, D.C. 20044-0582
9. I certify that the items listed herein are correct.
Signature of authorized
official
Date
Number Enrolled
Benefit Category Dollar Amount Deductions Made No Deductions Made
A. Life Insurance
1. Basic
2. Standard - Option A
3. Additional - Option B
a. To age 35
b. 35-39
c. 40-44
d. 45-49
e. 50-54
f. 55-59
g. 60 & up
4. Family - Option C
5. Post-Retirement - Basic
6. Total Life Insurance *
B. Health Benefits
1. Regular
2. Payers of Full Premiums
3. Total Health Benefits *
* Dollar amounts must agree with SF 2812 for same reporting period.
Public Burden Statement
We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments
regarding our time estimate or any other aspect of this form, including suggestions for reducing completing time, to the Office of Personnel Management, Funds Management, P.O. Box 582,
Washington, DC 20044. The OMB Number 3206-0262 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Office of Personnel Management This form may be locally reproduced
CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions unusable
OPM Form 1523
Revised October 2014
Page 1
click to sign
signature
click to edit
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