Fillable REVERSE USERRA ELECTION OPTIONS Please indicate your election (Arizona)

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REVERSE USERRA ELECTION OPTIONS Please indicate your election (Arizona)

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REVERSE USERRA ELECTION OPTIONS
Please indicate your election and acknowledgment by placing your INITIALS in the spaces provided below. If not
applicable, leave blank.
NAME: ___________________________________ WORK LOCATION: ______________________________________
(Print) (Last, First, MI)
POSITION TITLE/GRADE: __________________________________________________________________________
SUPERVISOR (CIV):_____________________________________ __________________________________
(PRINT) (PHONE)
1. Military Separation Orders and DD 214:
[_______] I have/will provide a copy of Military Separation Orders and DD 214 from current deployment.
2. SF-52:
[_______] I have/will notify my supervisor that a Return to Duty (RTD) SF 52 Request for Personnel Action
MUST BE SUBMITTED TO THE HRO.
3. Current Work Schedule:
[_______] 4/10 Work only four days a week for 10 hours a day with either Monday OR Friday as a day off
[_______] 9/8 Work eight 9 hour days & one 8 hour day in a two week period with Monday OR Friday off
[_______] 5/8 Work Monday thru Friday 8 hours a day
4. Leave: (I wish to use one of the following)
FROM TO
[_______] Terminal Military Leave _________________ _________________
I must submit a copy of my AF Form 988 (AIR) or DA 31 (ARMY) to HRO.
[_______] Personal LWOP _________________ _________________
I must inform my supervisor and turn in a COPY of my OPM 71 to HRO.
5. Return to Duty Effective:
[_______] I will return to Duty Effective: ____________________
[_______] I am currently on terminal leave and elect to:
[_______] Return to work before my orders end, Effective: ____________________
[_______] Return at the end of my Terminal Leave, Effective: ____________________
2 Revised May 26, 2020
6. Presidential Leave: (Contingency Only)
[_______] In accordance with Executive Order 13223, I am entitled to 5 days excused absence upon my
return from military service in connection with Operation ______________________. Your
supervisor must grant you 5 days of CONSECUTIVE administrative leave (LV) upon Return to
Duty (RTD) (if you were on contingency active duty orders. The 5 days of Presidential Leave is
authorized in a 12 month period after 42 consecutive days of Title 10 contingency orders.
FROM TO PHYSICAL RETURN TO WORK DATE
___________________ __________________ ____________________________
7. Federal Employee Health Benefits (FEHB):
Non-Contingency:
[_______] I do not have FEHB.
[_______] I elected to continue my FEHB coverage for up to 24 months while on military duty. Upon my
return to duty I understand that I have 60 days to change or select a different plan for FEHB.
[_______] I elected to terminate my FEHB while on military duty. I understand that upon my return to duty,
my FEHB will be restored effective the beginning of the pay period of my return to duty date.
Contingency:
[_______] I elected to continue my FEHB for up to 24 months while on military duty. Upon my return to
duty, I understand that I may elect to change or cancel FEHB within 60 days of restoration by
completing the transaction through the EBIS web site.
[_______] I elected to terminate my FEHB while on military duty. I understand that if I wish to take
advantage of Transitional TRICARE I must complete a WAIVER FORM prior to my RTD date on the
SF 52. The FEHB WAIVER is to be submitted the pay period prior to your Return to Duty,
otherwise your FEHB will be reinstated on your Return to Duty (RTD) date and premiums will
resume. You can return to FEHB 31 days before or 60 days after loss of Transitional TRICARE
using Event Code 1M in EBIS.
***MY TRICARE EXPIRATION DATE IS: ___________________________________________
8. Federal Employee Dental and Vision Insurance Plan (FEDVIP):
[_______] I understand that upon my return to duty I have 60 days to enroll or re-enroll in the Federal
Employee Dental and Vision Insurance Program (FEDVIP) the new vision and dental benefit
program separate from FEHB. In order to enroll or re-enroll I must go to the website or call
1-877-888-3337. If I don’t enroll within 60 days of my return to duty I will have to wait for the
open season which is the same as the FEHB Open Season (Nov–Dec timeframe).
www.benefeds.com
3 Revised May 26, 2020
9. Flexible Spending Account (FSA):
[_______] I understand that upon my return to duty, I may contact FSA to re-enroll in the program due to a
Qualifying Life Event (QLE) at www.fsafeds.gov or by calling 1-877-372-3337.
10. TRICARE Reserve Select (TRS):
[_______] I understand that because I am eligible for or enrolled in FEHB program, I am NOT eligible for
TRS. Failure to report your FEHB eligibility to TriWest, you will have to pay TriWest back ALL
monies paid on claims back to the date you became eligible for FEHB, plus you many face up to a
$5,000 fine, insurance fraud and imprisonment.
11. Federal Employees Group Life Insurance (FEGLI):
[_______] I do not have FEGLI.
[_______] I was not on AUS for more than 12 months.
[_______] I was on AUS for more than 12 months and elected to terminate. Your FEGLI will be reinstated
automatically upon my return to a pay and duty status in a FEGLI-eligible position.
[_______] I was on AUS for more than 12 months and elected to continue my FEGLI coverage for an
additional 12 months. Upon my return to duty the premiums will be reinstated and the
deduction will resume from my pay.
12. National Guard Association of the United States (NGAUS):
[_______] I do not have NGAUS.
[_______] I understand that upon entering in an AUS status that my NGAUS coverage was either continued
at my own expense (direct billed) or terminated. Upon my return I would like to reinstate
insurance and resume payroll deduction of the following coverage.
[_______] Basic and Supplemental Disability ________Reinstate (Please see NGAUS election form)
[_______] Term Life ________Reinstate (Please see NGAUS election form)
13. National Guard Association of the United States (NGAUS): (CONTINGENCY ONLY)
[_______] I served in support of a contingency; I have 31 days of resuming my technician duties to enroll.
(Guarantee Disability Insurance with no health questions or exams required.) ALSO Guaranteed
Life Insurance up to $50,000 for technician. I MUST COMPLETE ENROLLMENT APPLICATION.
4 Revised May 26, 2020
14. Thrift Savings Plan (TSP):
[_______] I understand that if I exercise restoration rights, I may make retroactive contributions and
elections to my TSP account. To do this, I must send a written request or fill out a form to
makeup TSP contributions at the ABC-C website within 60 days of my return to civilian service.
https://www.abc.army.mil/TSP/WhatisTSPMake-Up.htm
[_______] I have a TSP Loan(s). Attached is my form TSP-41 to be submitted to TSP for notification that I am
no longer in a non-pay status. I understand that I must make sure that DFAS has restarted my
loan payments to TSP upon my return to technician status.
[_______] 1% agency contributions are automatic, if eligible, upon my return to technician status. 1%
retroactive agency contributions will be completed upon return to duty date by the HRO office.
15. Military Buy-Back:
[_______] I understand that in order to complete a military deposit for this military tour, I must go to the
following website and complete the forms and steps,
https://www.abc.army.mil/retirements/FERSPost56.htm
16. Rideshare / Vanpool Program:
[_______] Yes, I am participating in the Vanpool program and will contact phone number on debit card to
restart enrollment.
17. Allotments / Garnishments:
[_______] I understand that upon returning from my non-pay status I will be responsible for re-
establishing any allotments/garnishments that were deducted from my pay prior to entering a
Absent Uniformed Service (AUS) status. It is also my responsibility to notify payees of the change
in my status.
5 Revised May 26, 2020
Statement of Understanding:
I understand the elections I have made above by signing, dating, and returning a copy of the Reverse USERRA
Election Options Form to: OTAG-AZ, HRO
5636 E. McDowell Rd, Bldg. M5710
Phoenix, AZ 85008-3495.
I also understand I am responsible for making sure the HRO has all forms: 1) USERRA Election Options Form, 2)
Military Orders, and 3) SF-52 necessary to process my AUS or separation action. All three of the forms listed
above are to be sent to the HRO as soon as possible.
_____________________________________________ ____________________________________
(Signature) (Date)
PHONE NUMBER: (Personal) __________________________________
(Work) _____________________________________
If you have any questions, please see contacts below.
REVERSE USERRA BRIEFER: ___________________________________________ DATE: _________________________
HRO CONTACTS:
Stacey Mitchell, Lead HR Specialist
Phone: 602-629-4806
Email: Stacey.A.Mitchell6.mil@mail.mil
Cristian Acosta, Human Resources Specialist
Phone: 602-267-2057
Email: cristian.g.acosta2.mil@mail.mil
Samantha Tellez, HR Specialist
Phone: 602-629-4818
Email: samantha.l.tellez.mil@mail.mil
HRO Main Line
Phone: 602-629-4800
Desiree Sheeran, HR Specialist
Phone: 602-629-4817
Email: desiree.j.sheeran.civ@mail.mil
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REVERSE USERRA ELECTION OPTIONS Please indicate your election (Arizona)

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Completed 27 January 2021

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