1. Is the beneficiary named on the front side of this form still living? Date of Death (mm/dd/yyyy)
Yes No (If no, please indicate the date of death.)
2. Are you currently the representative payee for the above named annuitant?
Yes No (Please provide a name and address of the person responsible in the Remarks Section below.)
3. Where does the beneficiary live?
Elsewhere (In the Remarks Section, please provide the name and
With you. In his or her own home.
address of the person or facility caring for the beneficiary.)
4. If you are receiving payment on behalf of a child, including adult disabled dependents, has the child married?
Yes (Please attach a copy of the marriage certificate.)
No Not applicable
5a. Has the beneficiary earned money during the survey period?
No
Yes (Please enter earnings in 5b. Do not include Social
Security benefits.)
Amount Earned, if yes to
Question 5a.
5b.
6. Did you turn over any of the annuity benefits to another person during the survey period?
$
No Yes (Please explain in the Remarks Section.)
7. Did you place any of the money in savings for the future needs of the beneficiary?
Yes (Please list the name and address of the financial institution
No (Please explain in the Remarks Section.)
in the Remarks Section.)
8. Did you spend all of the money on the beneficiary?
Yes No (Please explain in the Remarks Section.)
9. Beneficiary's Social Security Number
Remarks Section (Please use a separate sheet of paper if additional space is required.)
Warning:
Any intentionally false statement in this response or willful misrepresentation relative thereto is a violation of the law
punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
Privacy Act and Public Burden Statement
Signature of representative payee
Daytime phone number (including area code)
Date (mm/dd/yyyy)
Email address Social Security number or
Taxpayer Identification number
Title 5, chapter 83, U.S. Code, section 8347, and title 5, Chapter 84, U.S. Code, Section 8461, authorize the solicitation of the information to determine if we will be able to
continue paying you for the beneficiary. This information may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching
programs, with national, state, local, or other charitable or social security administrative agencies to determine benefits under their programs, to obtain information necessary
for determination or continuation of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above, with law
enforcement agencies, when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of
the Social Security Number. Providing this information is voluntary; however, without your signature and all of the information requested, it may be impossible for us to
continue to pay you, and we may suspend these benefits.
We estimate completing this form takes approximately 20 minutes. 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, Retirement Services Publications Team (3206-0208), Washington, DC 20415-3430. The OMB number,
3206-0208, is currently valid. OPM may not collect this information, and you are not required to respond, unless the number is displayed.
Reverse of RI 38-115
Revised August 2010
