United States
Office of Personnel Management
Retirement & Benefits
Washington, DC 20415
Federal Employee Retirement Coverage Corrections Act (FERCCA)
Election Form
I have read the FERCCA Election Summary material provided to me by .
I have had the opportunity to receive counseling on my options and have received sufficient information to make an
informed decision. I understand my options with regards to the Federal Erroneous Retirement Coverage
Corrections Act (FERCCA), and I therefore, make the following election. I understand this election is final and
irrevocable.
Name (last, first, middle)1. 2. Date of birth (mm/dd/yyyy) 3. Social Security Number
4. Home Address (number, street, city, state, ZIP code)
Enter the agency name
5.
4a. Home telephone number (including area code)
4b. Work telephone number (including area code)
4c. Email address (if applicable)
4. Home Address (number, street, city, state, ZIP code)
Election:
Plan name: _________________________________
Retirement
Plan name: __________________________________
Retirement
6.
Do you have a qualifying court order on file with the Office of Personnel Management that gives a portion of your annuity or survivor annuity to a former spouse?
Yes No
6a. If the answer is yes, a SF 3110, Former Spouse's Consent to FERS Election, needs to be completed by you and your former spouse (notarized). This form
does not need to be completed if (check the appropriate box):
You are legally separated, but there is no divorce decree.
After the divorce, your former spouse remarried before the age of 55 (it does not matter if your former spouse is no longer married.)
You are in CSRS or CSRS Offset and elect to stay in CSRS or CSRS Offset.
You are in FERS and Elects CSRS or CSRS Offset.
Signature Date
This form may be reproduced locally
RI 10-125
May 2010
