Fillable Ri30-010 2018 05 RI30-010: Disabled Dependent Questionnaire

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Ri30-010 2018 05 RI30-010: Disabled Dependent Questionnaire

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Disabled Dependent Questionnaire
RI 30-10
Previous editions are usable. Revised May 2018
Form Approved:
OMB No. 3206-0179
United States
Office of Personnel Management
Retirement Benefits Branch
1900 E Street NW - Room 2416
Washington DC 20415-0001
1. Name of disabled dependent (last, first, middle) 2. Dependent's date of birth (mm/dd/yyyy)
3. Name of annuitant or deceased annuitant (last, first, middle) 4. Claim number
CS
Complete Part A below and ask the physician to complete Part B on the other side of this form.
Part A - To Be Completed by Disabled Dependent or Dependent's Guardian or Other Fiduciary
1. Disabled dependent's Social security number
2a. The unmarried disabled dependent lives:
with parent[s] (go to 2b)
with guardian or other fiduciary (go to 2b)
in a licensed facility (go to 2b)
2b. Please provide the disabled dependent's address and the name of the person
that he or she lives with.
2c. The disabled dependent is married. (Provide a copy of the marriage
certificate, complete item 7, and return the form to us.)
3. Is there a court appointed guardian or other fiduciary to handle the affairs of the disabled dependent?
Yes. If "yes," the guardian or other fiduciary must attach a copy of the court
appointment, provide his or her Social Security (SSN) or Taxpayer
Identification Number (TIN), and complete item 7 below.
SSN or TIN
No
4. Has the disabled dependent been employed during the last twelve months?
Yes No
Go to question 6.
5a. Periods and type of employment:
From (mm/dd/yyyy) To (mm/dd/yyyy) Description of work performed
5b. Total earnings during periods of employment listed
in 5a:
$
5c. Was employment in a closely supervised environment, eg. closed workshop?
Yes
No
6. Highest level of education of disabled dependent:
7. Certification
I certify that the above statements are true to the best of my knowledge and belief. I hereby authorize the release of
medical evidence and information to the Office of Personnel Management (OPM).
Signature of disabled dependent, guardian, or other fiduciary Date (mm/dd/yyyy)
Telephone number
( )
Email address
Please have the unmarried disabled dependent's physician complete the back of this form and return the completed form to the
above address
PRINT
SAVE
CLEAR
Reverse of RI 30-10
Revised May 2018
Part B - To Be Completed by the Physician
In order to determine if your patient is eligible for benefits under the retirement law, we need information regarding the patient's
current medical condition.
1. Diagnosis of disability:
2. Estimate of the expected
date of full or
partial recovery:
3. Age at onset: 4. Severity of disability:
Mild
Moderate
Severe
5. If patient is mentally
disabled, state
approximate mental age:
6. If patient is mentally
disabled, give results
of IQ tests:
In addition, please attach a narrative (on your letterhead stationery) addressing the following points:
1. The history of the specific medical condition(s), including references to findings from previous examinations, treatment, and
responses to treatment.
2. Clinical findings from your most recent medical evaluation, including findings of physical examinations, results of laboratory
tests, X-rays, EKG's and other special evaluations or diagnostic procedures and, in the case of psychiatric disease, the findings of
mental status examinations and the results of psychological tests.
3. Assessment of the current clinical status and plans for future treatment.
4. Assessment of the degree to which the medical condition has or has not become static, well stabilized, or controlled, and an
explanation of the medical basis for the conclusion.
5. Specify the physical and/or mental limitations or restrictions caused by the patient's medical condition(s).
6. Does the patient's condition preclude or limit self-supporting employment? Explain your answer.
7. If the patient is incapable of self-support, at what age did the patient become incapable?
8. Can the patient handle his or her own finances?
Signature Print or type name
Date (mm/dd/yyyy)
Address
Telephone number (including area code)
E-mail address
Return the completed form and the narrative to the address on the front of the form.
Privacy Act Statement
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is
authorized to collect the information requested on this form by 5 U.S.C. Chapters 83, 84, and 89. OPM is authorized to collect your Social Security number by
Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008). Purpose: OPM is requesting this information in order to
determine whether the disabled dependent is eligible for continued benefits. Routine Uses: The information requested on this form may be shared externally as a
"routine use" to other Federal agencies and third-parties when it is necessary to process your request. For example, OPM may share your information with other
Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain information necessary for a determination of your
suitability, or to report income for tax purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a violation or potential
violation of civil or criminal law. A complete list of the routine uses can be found in the OPM/CENTRAL 1 Civil Service Retirement and Insurance Records
systems of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide Information: Providing this information is voluntary.
However, failure to provide this information may result in our inability to allow benefits.
Public Burden Statement
We estimate providing this
information takes an average 60 minutes per response to complete, including the time for reviewing instructions, getting the needed data,
and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the
U.S. Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0179), Washington, DC 20415-0001. The OMB Number 3206-0179 is
currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
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Ri30-010 2018 05 RI30-010: Disabled Dependent Questionnaire

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Completed 29 February 2020

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