Form approved:
OMB No.: 3206-0245
Claim number
CSA
U.S. Office of Personnel Management
Retirement Operations Center
Post Retirement
Attention: Y-Adjustment
P.O. Box 45
Boyers, PA 16017-0045
Request for Change to Unreduced Annuity
In order to change my benefit to the unreduced annuity rate, I am providing the information
below.
The reason my marriage ended is:
Spouse Died Divorce Annulment
The date my marriage ended is:
I have enclosed: (Check one block below.)
A copy of the death certificate.
A court-certified copy of my divorce decree, including all property settlements.
A court-certified copy of my annulment.
I understand that if I have self and family health benefits coverage, I can change to self-only at
any time.
Change my coverage to self-only.
(Note: Check this block if you want to make the change. A former spouse is no longer a family
member and is not eligible for coverage under your family enrollment.)
Name (last, first, middle initial)
Signature (do not print) Date (mm/dd/yyyy) Telephone no. (include area code)
Email address
Public Burden Statement
We estimate this form takes an average of 30 minutes per response to complete. Send comments regarding our estimate or
any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management,
Retirement Services Publications Team (3206-0245), Washington, D.C. 20415-3430. The OMB number 3206-0245 is
currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
RI 20-120
Previous editions are not usable.
Revised March 2012
