Form approved:
OMB No. 3206-0167
Financial Resources Questionnaire
Federal Employees Health Benefits Premiums Underpaid
U.S. Office of Personnel Management
Retirement Operations
General Information
The purpose of this questionnaire is to determine your eligibility for:
1. waiver of the amount due the retirement system on the basis of
financial hardship;
2. compromise in the amount to be paid;
3. lower installments; and/or
4. a voluntary payment agreement.
For more information on waiver, compromise, lower installments, or
voluntary payment, please refer to our letter or notice informing you of the
underpayment of Federal Employees Health Benefits premiums.
(Note: If you are only requesting lower installments, you do not need to
fill out this questionnaire as long as your payments will be (1) at least $50
a month and (2) sufficient to pay off the entire amount within three years.)
Failure to supply all the requested information may result in an
unfavorable decision. Please note that you may be asked to provide
verification of the information you supply in this questionnaire (e.g.,
evidence of claimed expenses).
To be considered for waiver, compromise, lower installments, or a
voluntary payment agreement, you must complete and return this
questionnaire to us within 30 days after the date shown in the notice of
underpayments.
General Instructions
1. Please read all items carefully.
2. Type or print in ink.
3. Complete all items on the form. If a question does not apply, answer
“No” or “None”. Do not leave it blank. If answers require additional
space, continue them in Section X. Attach additional sheets if
necessary. Include your name and retirement claim number in the
upper right corner of each additional sheet.
4. Sign and date this questionnaire in Section XI.
5. Send the completed form to:
Office of Personnel Management
Attn: Funds Management
P.O. Box 7125
Washington DC 20044-7125
Detailed Instructions
Most of the questionnaire items are self-explanatory. Instructions are
provided below for those items identified with an asterisk(*), which
require further explanation.
Section I - Personal Data
Item 1 Give the name of the former Federal employee upon whose
service your entitlement to retirement system benefits was
based. (If the benefits are based upon your own service, give
your name.)
Section IV - Average Monthly Income
Item 1 Enter your current monthly gross salary - i.e., wages, fees,
commissions - for yourself and then your spouse. (Enter the
total
salary paid before any payroll deductions are made; e.g.,
Federal, state, and local taxes; social security taxes; insurance,
etc.). If your salary fluctuates on a monthly basis, estimate the
monthly average.
Item 6 Enter all other current income not listed. This may include
unemployment compensation, public assistance benefits, trust
income, tax refunds, alimony, child support, royalties,
payments of debts owed to you, income provided by
dependents listed in Section I (other than spouse), etc. Estimate
the average monthly amount.
Section V - Average Monthly Expenses
Item 1 Enter the amount you currently spend on average for rent,
mortgage, homeowner/condominium fees, etc., each month. If
you include property taxes in this item, do not include them in
V.9.
Item 3 Enter the average monthly amount you spend for electricity,
telephone, gas, water, coal, oil, etc.
Item 4 Enter the average monthly amount you spend for household
maintenance (repairs, cleaning supplies, etc.) and personal
necessities.
Item 7 Enter the average monthly amount you spend for insurance
(life, health, accident, automobile, homeowners, etc.). Do not
include homeowner’s insurance if it is already included in item
V.1.
Item 8 Transportation costs include necessary automobile expenses
(gas, oil, maintenance), cab fares, and public transportation.
Item 9 Enter 1/12 of all taxes you pay in a year, including Federal,
state, and local taxes; property taxes not included in item V.1;
sales taxes not included in other items, etc.
Item 10 Enter the total amount due monthly from existing liabilities as
shown in Column E of Section VII. (This amount should not
include any expenses - such as mortgage payments - listed
under other items in Section V.)
Item 11 Other living expenses which you can prove to be ordinary and
necessary. Provide a breakdown of these expenses in Section
X.
Section VIII - Assets
Item 4 Enter the cash value of your money market accounts,
certificates of deposit, etc. Do not include Individual
Retirement Accounts (IRA’s) or other interest bearing accounts
which belong in item 6.
Item 5 The current value on any stocks or bonds you own. The current
value is the amount you would receive if you sold these
securities.
Item 6 The current value of any IRA’s, Keoughs or similar retirement
savings accounts.
Item 8 Identify any automobiles, vans, trucks, motorcycles, motor
homes (RV’s), trailers, campers, boats, etc., that you own, and
their resale value (the amount you would receive if you sold
these vehicles). Any remaining liabilities for these vehicles
should appear in Section VII.
Item 9 The resale value of your home and other real estate. (If you
own two or more properties, list separately. Also show the
unpaid amount of any real estate mortgages in Section X.)
Item 10 The current resale value of any other personal property (art
pieces, jewelry, etc.) which can be sold and which are valued in
excess of $1,000 per item. (Itemize in Section X.)
RI 34-18
Previous editions are not usable.
Revised May 2012
