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Application for Immediate Retirement
Civil Service Retirement System (CSRS)
Introduction
If you are a current Federal or Postal Service employee covered
by the Civil Service Retirement System and you wish to apply
for retirement with an immediate annuity (annuity commencing
within one month after the date of separation on which title to
annuity is based), this package is for you! If you are covered
by the Federal Employees Retirement System, you must use
SF 3107 to apply for an immediate annuity retirement.
If you are applying for disability retirement, you must
complete both this application and Standard Form 3112,
Application for Disability Retirement. Ask your agency for
this form. You, your physician, and your agency must
complete the various portions of SF 3112. The Office of
Personnel Management (OPM) must receive the SF 3112
within one year after the date you separate.
Do not use this package or the forms it contains to apply for
deferred annuity. If you want to apply for a deferred annuity
(generally beginning at age 62), you should request an
application from the Office of Personnel Management, Civil
Service Retirement System, Retirement Operations Center,
Boyers, PA 16017.
Keep the information section of this package for future
reference.
Where to Obtain Additional Information
This package presents basic retirement information about
matters affecting most retiring employees. Contact the Human
Resources Office at the agency where you work for retirement
counseling, detailed information, and other assistance you
need to prepare for retirement. Your agency must certify that
you are eligible for an immediate annuity. OPM employees
cannot advise you before you are separated and your certified
records are forwarded to OPM.
General Information
This package contains the following:
1) Instructions for the completion and submission of the
SF 2801, Schedules A, B, C, and SF 2801-2.
2) Additional information about retirement, including:
•
Post-1956 Military Service, page 4
•
Important Information About Survivor Annuity
Elections, page 5
•
Survivor Annuity Election Changes After Retirement,
page 7
•
How Annuities Are Computed, page 8
•
Cost-of-Living Increases, page 10
•
Payment and Accrual of Annuity, page 10
•
Filing Your Application, page 10
•
What Happens After You File Your Retirement
Application, page 11
•
What To Do If Your Address Changes Before
Processing Is Completed, page 11
4) Schedules A, B, and C to be completed by the retiring
employee if he or she has (1) active duty military service,
(2) has ever applied for military retired pay and/or pension
or compensation from the Department of Veterans Affairs
in lieu of military retired pay, or (3) has applied for
compensation benefits from the Office of Workers'
Compensation Programs, U.S. Department of Labor.
5) SF 2801-2, Spouse's Consent to Survivor Election, to be
completed by the retiring employee, his or her current
spouse, and a notary public (or other person authorized to
administer oaths) in cases where a married applicant elects
less than the maximum survivor annuity for the spouse.
6) SF 2801-1, Certified Summary of Federal Service, to be
completed by the employing agency and signed by the
applicant after reviewing the information the employing
agency enters.
7) Agency Checklist of Immediate Retirement Procedures, to
be completed by the employing agency and, to the extent
possible, reviewed by the retiring employee to help assure
completeness and correctness of the submission.
Instructions for Completing Application
for Immediate Retirement
Type or print clearly. If you need more space in any section,
use a plain piece of paper with your name and date of birth
written at the top. If you do not know an answer write
“unknown.” If you are not sure (for example, if you do not
know an exact date), answer to the best of your ability,
followed by a question mark (?).
Refer to the pamphlet SF 2801A, Applying for Immediate
Retirement Under the Civil Service Retirement System, for
additional information about those questions on the
application which are not entirely self-explanatory.
Section A - Identifying Information
Item 2: List other names under which you have been
employed in the Federal government (such as a
maiden name). This will help OPM locate and
identify records maintained under these names.
Item 3: Enter the address to which correspondence should be
mailed. If you want your payments sent to a bank or
other financial institution, do not enter the bank
address here; see Section H of the application form.
Item 6: List all social security numbers you have used.
Section B - Federal Service
Item 2: Enter the date of final separation for retirement.
Leave blank if applying for disability retirement and
not yet separated. Please note that if you are currently
serving in more than one appointive or elective
position in the Federal Government, you must
separate from all such positions before you can
qualify for an immediate retirement.
3) SF 2801, Application for Immediate Retirement, to be
completed and signed by the retiring employee.
U.S. Office of Personnel Management
(See page 11 for the Privacy Act Statement.)
Standard Form 2801
CSRS/FERS Handbook for Personnel and Payroll Office
2801-111
Revised June 2013
NSN 7540-00-634-4250 Previous editions are not usable.
Item 4: Indicate whether or not you have performed active
duty that terminated under honorable conditions in
the armed forces or other uniformed services of the
United States, including the following:
(a) Army, Navy, Marine Corps, Air Force, or
Coast Guard of the United States,
(b) Regular Corps or Reserve Corps of the
Public Health Service after June 30, 1960,
(c) Commissioned Officer of the National
Oceanic and Atmospheric Administration or
a predecessor entity in function after June
30, 1961.
(d) Cadet at the U.S. Military Academy, U.S.
Air Force Academy, U.S. Coast Guard
Academy, or Midshipman at the U.S. Naval
Academy.
(e) Excluding the National Guard, active service
in the reserve components of the uniformed
services, including active duty for training, is
military service. Service as a National Guard
member does not meet the definition of
military service for purposes of civil service
retirement, except when the member is
ordered to active duty in the service of the
United States or performs full-time National
Guard Duty (as such term is defined in
section 101(d) of title 10) if the National
Guard duty interrupts creditable civilian
service under subchapter III of chapter 83 of
title 5, and is followed by reemployment in
accordance with chapter 43 of title 38 that
occurs on or after August 1, 1990.
If you have performed such service, complete
and attach Schedule A, furnishing the requested
information from the military for each period of
active duty. Provide evidence of active duty you
claim. You are responsible for obtaining this
information and submitting it to OPM to substantiate
your claim. OPM may verify the information with the
military service.
Item 5: If you are receiving, or have applied for, any form of
military retired pay and/or pension or compensation
from the Department of Veterans Affairs in lieu of
military retired pay, answer “yes” to item 5, then
complete and attach Schedule B - Military Retired
Pay. Important: Military retired pay includes
disability pay and reserve retainer pay.
Section C - Other Claim Information
Item 2: Indicate whether or not you have ever applied for
retirement, refund, deposit or redeposit, return of
excess deductions, or voluntary contributions under
the Civil Service Retirement System. If you have,
indicate which type in 2a and the applicable claim
numbers in 2b. This helps to assure that all of your
records are located and that proper credit is given
for your service, and for any deposit, redeposit or
voluntary contribution payments you may have
made.
Section D- Insurance Information
If you want to continue your Federal Employees Health
Benefits (FEHB) and/or Federal Employees' Group Life
Insurance (FEGLI) coverage as a retiree, you must meet the
following basic requirements. You must be retiring on an
immediate annuity, and you must have been enrolled in the
program for the five years of Federal service immediately
preceding your annuity commencing date, or if enrolled less
than five years, for the full period(s) of service during which
coverage was available. FEHB coverage as a family member
(and coverage under TRICARE) counts toward the five-year
requirement for health benefits.
If you do not meet the enrollment requirement for continuing
your FEHB coverage as a retiree, you may be eligible for
temporary continuation of coverage as a separated employee.
Your employing office will provide information about
whether you can temporarily continue your FEHB coverage
and how to enroll for it.
If you appear eligible to continue your FEHB coverage, your
agency will automatically transfer your enrollment to OPM.
You do not need to do anything unless you want to make
some change in your coverage.
If you are enrolled in the Federal Dental and Vision Program
(FEDVIP), you may be billed for the premiums from the time
you separate for retirement until OPM completes work on
your retirement application. You must pay these bills in order
to keep your FEDVIP coverage. After work on your
retirement application is completed, OPM will deduct your
FEDVIP premiums from your monthly annuity payments. If
you retire on an immediate annuity, you can enroll in FEDVIP
during any Federal Benefits Open Season.
The FEGLI Program booklet (RI 76-21) has information
about eligibility to continue your FEGLI coverage as a retiree
and the cost of coverage. If you are eligible to continue your
FEGLI basic coverage, you MUST complete an SF 2818,
Continuation of Life Insurance Coverage as an Annuitant or
Compensationer. Any optional FEGLI coverage you have
and are eligible to retain as a retiree will automatically be
continued unless you make some change. You may also want
to file a FEGLI Designation of Beneficiary form (SF 2823).
If you are under age 65 and elect to continue Basic life
insurance coverage into retirement, you must pay the same
premium as active employees until you reach age 65. If you
elect either the 50% or No Reduction schedule (for coverage
after reaching age 65) on the SF 2818, you must pay not only
the regular insurance premium but also the additional premium
required for the extra coverage you will have after age 65.
Premiums for the additional coverage after age 65 continue for
life or for as long as you maintain the extra coverage.
Based on the documentation your employing agency is
required to submit with your retirement application, OPM will
determine whether you are eligible to continue your health
and life insurance coverage as a retiree. However, if you have
any questions about your eligibility, ask your employing office
for assistance before you retire.
Section E - Marital Information
Item 2: You must complete this item. Indicate whether or
not you have a living former spouse from whom you
were divorced on or after May 7, 1985, and to whom
a court order gives a survivor annuity or awards a
portion of your retirement benefit based on your
Federal employment.
If you answer yes, attach a certified copy of the court
order/divorce decree in its entirety and any
attachments or amendments. Failure to complete
this item will delay the processing of your
application.
Standard Form 2801
-2-
Previous editions are not usable. Revised June 2013
Section F - Annuity Election
Read “Important Information About Survivor Annuity
Elections,” page 5, before making your election. If you initial
either Box 1 or Box 2, your wife or husband will receive a
survivor annuity upon your death. The amount of this survivor
annuity, and the amount of the reduction in your annuity to
provide this benefit, will depend on which election you initial.
If your spouse is not elected to receive a monthly survivor
annuity, his or her health benefits coverage as a family
member on your FEHB enrollment will terminate when you
die.
For information on the effect of court orders on your spouse's
eligibility to receive survivor benefits, see page 5.
Box 1: If you initial box 1, your spouse's survivor annuity
upon your death will be 55% of your unreduced
annuity. Your annuity will be reduced by 2½ percent
of the first $3,600 and 10% of the remainder of your
annual annuity to provide this benefit upon your death.
Box 2: If you initial box 2, your spouse's survivor annuity
upon your death will be 55% of the annual amount
you specify in the blank space (which must be less
than the full amount of your annual annuity). Your
annuity will be reduced by 2½ percent of the first
$3,600 and 10% of any additional amount you
specify.
If you initial box 2, you must complete and attach
SF 2801-2, Spouse's Consent to Survivor Election,
to your application. The law requires consent of the
spouse if a married person elects less than the
maximum survivor benefit.
Box 3: If you initial box 3 you will receive an annuity
payable only during your lifetime, without a monthly
survivor annuity for your spouse. All retiring
employees, married and unmarried, may choose this
type of annuity. However, you should carefully
review all information provided before making your
election.
If you are married at retirement and choose this type
of annuity, you must also complete and attach to
your application SF 2801-2, Spouse's Consent to
Survivor Election. The law requires that your
spouse consent if you elect less than maximum
survivor benefits.
Box 4: If you initial box 4, a person selected by you, who
has an insurable interest in you, will receive a
survivor annuity upon your death. Insurable interest
exists if the person named (such as a former spouse
or a close relative) may reasonably expect to derive
financial benefit from your continued life.
To choose this type of annuity, you must provide
medical documentation showing that you are in good
health. You are responsible for arranging and paying
the costs of the medical examination. The medical
report of the examination should be attached to your
retirement application. You will be notified if
additional evidence is required. Note: If you are
retiring on the basis of disability, you are not eligible
to choose this type of annuity.
You may elect this insurable interest survivor annuity
in addition to a regular survivor annuity for a current
or former spouse. However, if the person you select
to receive the insurable interest survivor annuity is
your current spouse, you both must waive the
current spouse annuity by completing and attaching
SF 2801-2 to your application. Your current spouse
cannot receive both a regular survivor annuity and
an insurable interest survivor annuity.
If you elect the insurable interest annuity for a
current spouse because a court order awards (or you
have elected) the regular survivor annuity to a former
spouse, the insurable interest election for your
current spouse can be converted to a current spouse
annuity if the former spouse loses entitlement to the
regular annuity through death or remarriage prior to
reaching age 55. The marriage duration requirement
(see item c on page 5) does not apply to insurable
interest annuities.
If you choose to provide an insurable interest
survivor annuity, the amount of the reduction in your
annuity will depend upon the difference between
your age and the age of the person named as survivor
annuitant, as shown in the table below. The
survivor's rate will be 55% of your reduced annuity.
Age of Person Named in Relation
to that of Retiring Employee
Reduction in Annuity
of Retiring Employee
Older, same age,
or less than 5 years younger
10%
5 but less than 10 years younger
15%
10 but less than 15 years younger
20%
15 but less than 20 years younger
25%
20 but less than 25 years younger
30%
25 but less than 30 years younger
35%
30 or more years younger
40%
Box 5: If you initial box 5, you must complete the remainder
of Section F. Read item f. on page 5 before making
your election. If you are married and initial box 5,
you must also complete and attach SF 2801-2,
Spouse's Consent to Survivor Election, to your
application.
If you initial box 5, after your death, the person(s)
you elect will receive the percentage of the annuity
you select. Your annuity will be reduced by 2½
percent of the first $3,600 of all or a specified
amount of your annual self-only annuity and further
reduced by 10% for any portion of the base used
over $3,600 a year. If your annual annuity is $3,600
or less, only a 2½ percent reduction applies.
Section G - Information About Children
Information about your children in your annuity claim file
may help to expedite the processing of claims for survivor
benefits in the event of your death. Therefore, you may, if
you wish, complete Section G by providing the names and the
dates of birth of your unmarried dependent children under the
age of 22. List any child who is between 18 and 22 and is a
full-time student. List any child who is over the age of 18 and
incapable of self-support because of a mental or physical
disability incurred before age 18. Check the box headed
“disabled” by the name of each child to whom this applies.
Completion of Section G is optional; the processing of your
annuity application will not be delayed or otherwise affected
if you do not complete it. Children will not be denied benefits
after your death solely because they were not identified on
your retirement application.
Standard Form 2801
-3-
Previous editions are not usable. Revised June 2013
Section H - Direct Deposit/Direct Express and
Tax Withholding Information
The U.S. Department of the Treasury pays all federal benefits
electronically. If you are not enrolled in the Direct Deposit
program, you will need to enroll or to arrange for a Direct
Express debit card provided by the Department of Treasury.
To enroll in the Direct Deposit program, contact your
financial institution or OPM. To obtain a debit card, go to
www.godirect.org. If your payments are not electronically
deposited to your account and you do not have a Direct
Express card, you must contact the Department of the
Treasury at 1-800-333-1795 to discuss your options. This
does not apply if your permanent payment address is outside
the United States in a country not accessible via Direct
Deposit/Direct Express. Use Section H, items 1 through 3c
to tell OPM how to make payment to you.
Use Section H, item 4 to give OPM instructions regarding
Federal income tax withholding. If you do not give any
instructions, the Internal Revenue Service has instructed OPM
to withhold at the rate for a married person with three
exemptions.
After your application is processed, as discussed on page 11,
item 6, you will be able to instruct OPM to withhold State
income tax, provided your State participates in OPM's State
Tax Withholding Program.
Section I - Applicant's Certification
Be sure to sign (do not print) and date your application after
reviewing the warning.
Schedule A - Military Service Information
Item 2: Post-1956 Military Service -- If you performed
military service on or after January 1, 1957, you may
pay a deposit of 7% of your military basic pay (plus
interest, if applicable) to cover that service. The
military service deposit must be paid to your agency
while you are still employed. If the deposit is not
paid, your post-1956 military service will be credited
as described below.
If you were first employed in a position subject to
CSRS coverage before October 1, 1982: If you do
not make the deposit and you are eligible for Social
Security benefits at age 62, your annuity will be
recomputed (at age 62) to eliminate credit for the
post-1956 military service. If you are age 62 or older
when you retire and are eligible for Social Security
benefits, no credit for post-1956 military service will
be allowed in the computation of your annuity unless
you pay the deposit before you separate.
If you were first employed in a position subject to
CSRS coverage on or after October 1, 1982: You
will not receive any retirement credit for your
post-1956 military service if you do not make the
deposit for it before you separate.
The amount of a CSRS military deposit may be
different for an employee who has been absent from
civilian employment to perform honorable, active
military service that interrupted Federal civilian
service. Under certain conditions, the amount of the
military deposit for such a period of military service
would equal the amount of retirement deductions that
would have been withheld from Federal civilian basic
pay if the military service had not interrupted the
civilian service. Ask your benefits office about this
alternative military deposit calculation referenced in
5 U.S.C. 8334(j) if you think it may apply to you.
If you have questions concerning the crediting of
your post-1956 military service and how to make the
deposit, contact your employing agency. Failure to
pay the deposit to your agency voids any further
right to pay it at a later date.
Schedule B - Military Retired Pay
This information is needed to assure correct credit for military
service. Receipt of military retired pay or pension or
compensation from the Department of Veterans Affairs in
lieu of military retired pay may affect the computation of
your annuity rate. You cannot receive retirement credit for
military service if you receive military retired pay, unless
you were awarded the retired pay (a) due to a disability
incurred in combat with an enemy of the United States or
(b) under the provisions of Chapter 1223, title 10, U. S.
Code, Sections 12731 through 12739 (pertaining to
retirement from a reserve component of the armed forces).
If you are waiving military retired pay for civil service
retirement purposes, your agency can help you prepare your
request for waiver. Attaching a copy of your waiver request
and a copy of the finance center acknowledgment (if
available) to your application may help us to process your
claim more quickly. Even if you have already waived your
military retired pay to receive benefits from the Department of
Veterans Affairs, you also need to file a waiver of your
military pay for civil service retirement purposes.
Schedule C - Federal Employee's Compensation
Item 3:
Indicate whether you agree to notify us if the status
of your workers' compensation claim changes.
Important: You may not legally receive both
retirement annuity and workers' compensation
(except for a scheduled award) for the same period
of time. Any overpayment of workers' compensation
or retirement annuity you receive is subject to
collection by OPM or the Office of Workers'
Compensation Programs (OWCP).
The information requested regarding benefits from
OWCP is needed because the law prohibits the dual
compensation which would exist if you received both
a civil service retirement annuity and compensation
for total or partial disability under the Federal
Employees' Compensation Act. Note: The
Department of Labor has determined that the
alternative annuity lump sum payment is a payment
within the terms of the dual compensation provision.
If you receive the alternative annuity lump sum
payment and later elect compensation from OWCP,
no compensation would be payable until the amount
of the lump sum payment and all annuity paid is
returned to the Retirement Fund.
If you are applying for disability retirement, please
include, as part of your SF 3112 submission, all
medical evidence submitted to OWCP in connection
with your compensation claim and any OWCP
decision or evaluation of your claim.
Standard Form 2801
-4-
Previous editions are not usable. Revised June 2013
Important Information About
e.
Survivor Annuity Elections
The election you make at retirement is for the person named in
Section E. No one else can benefit even if you allow the
annuity reduction to continue after your marriage ends.
a. Married Employees. If you are married at retirement
and do not indicate your annuity election or your
spouse does not consent to an election of less than
the maximum survivor annuity, your application will
be processed on the basis of maximum survivor
benefits for your spouse.
b.
Spousal Consent Requirement.
(1) If you are married and you do not elect to
provide the maximum survivor annuity
benefit for your spouse by initialing Section
F, box 1 of the application, you must attach
a completed SF 2801-2, Spouse's Consent to
Survivor Election. This is required even if a
former spouse will be awarded a survivor
annuity by court order. See “Court-Ordered
Former Spouse Annuities” under item e.
(2) OPM may waive the spousal consent
requirement if you show that your spouse's
whereabouts cannot be determined. A
request for waiver on this basis must be
f.
accompanied by:
•
A judicial determination that your
spouse's whereabouts cannot be
determined; or
•
Affidavits by you and two other
persons, at least one of whom is not
related to you, attesting to the
inability to locate the current
spouse and stating the efforts made
to locate the spouse. You must
also give documentary evidence,
such as tax returns filed separately
or newspaper stories about the
spouse's disappearance.
(3) OPM may waive the spousal consent
requirement if you present a judicial
determination regarding the current spouse
that would warrant waiver of the consent
requirement based on exceptional
circumstances.
c. Marriage Duration Requirement. To be eligible for
survivor annuity after your death, your widow(er)
must have been married to you for a total of at least 9
months or be a parent of your child, provided all
other requirements are met. The marriage duration
requirement does not apply if your death is
accidental.
d. Survivor Annuity for Children. The eligibility of
your children for survivor annuity after your death
does not depend on your marital status or the type of
g.
annuity you elect. Your unmarried dependent
children may qualify for survivor annuity until age
18. Benefits may be payable to an unmarried child
after age 18 if the child is a full-time student at a
recognized educational institution or is incapable of
self-support due to a disability incurred before age
18. Benefits for a student child are generally not
payable after the child attains age 22.
-5-
Court-Ordered Former Spouse Annuities. If your
annuity begins on or after May 7, 1985, and a
qualifying court order gives (awards or requires you
to provide) a survivor annuity to a former spouse
from whom you were divorced on or after that date,
OPM must honor the terms of the court order, except
as discussed below. Your annuity will be reduced to
provide the survivor annuity for the former spouse if
he or she is eligible for this benefit. However, a
former spouse cannot receive a survivor annuity by
court order unless:
(1) He or she was married to you for at least 9
months;
(2) You have at least 18 months of service
subject to retirement deductions; and
(3) He or she has not remarried before reaching
age 55. This does not apply if you and your
former spouse were married for 30 years or
longer.
If you are married and a court has awarded a survivor
annuity to a former spouse, see item g. below, which
explains how you can protect your current spouse's
future survivor annuity rights.
Electing a Survivor Annuity For a Former Spouse
or a Combination of Survivor Annuities For
Current and Former Spouses.
(1) To make a former spouse annuity election,
you must have been married to the person
for a total of at least 9 months and you must
have at least 18 months of service that was
subject to retirement deductions. A former
spouse who marries again before reaching
age 55 is not eligible for a former spouse
survivor annuity, unless you and your
former spouse were married for 30 years
or longer.
(2) You may elect to provide a survivor annuity
for more than one former spouse whether or
not you are currently married. If you are
married, you may elect a survivor annuity
for your current spouse as well as a survivor
annuity for one or more former spouses.
However, the total of the survivor annuities
may not exceed 55% of your unreduced
annuity. Also, if you are married, you must
have your spouse's consent if you do not
elect the maximum current spouse survivor
annuity.
(3) To elect a reduced annuity to provide a
survivor annuity to a former spouse or a
combination of survivor annuities
for current and former spouse(s), complete
Section F, box 5.
Electing a Survivor Annuity For a Current Spouse
When a Court Order Gives a Survivor Annuity to a
Former Spouse.
(1) If a court order has given a survivor annuity
to a former spouse, you must make your
election concerning a survivor annuity for
your current spouse as if there were no
Standard Form 2801
Previous editions are not usable. Revised June 2013
court-ordered former spouse annuity. By (6) FEHB coverage for your widow(er) can
electing the maximum survivor benefit for continue only if he or she is elected to
your current spouse at retirement, you can receive a survivor annuity.
protect your spouse's rights in case your
former spouse loses entitlement in the future
h. Electing an Insurable Interest Annuity For a
(because of remarriage before age 55 or
Current Spouse.
death). You can do this because OPM must
Note: Disability annuitants cannot elect an insurable
honor the terms of the court order and you
interest survivor annuity.
are not required to elect a survivor annuity
for the former spouse. (Note: The election
(1) If a former spouse's court-ordered survivor
you make now regarding a survivor annuity
annuity will prevent your current spouse
for your current spouse cannot be changed
from receiving a survivor annuity that is
except as explained in “Survivor Annuity
sufficient to meet his or her anticipated
Election Changes After Retirement,” see
needs, you may want to elect an insurable
page 7.) The following paragraphs explain in
interest annuity for your current spouse.
more detail how your election at the time of
(2) If you elect an insurable interest survivor
retirement can affect your current spouse's
annuity for your current spouse, you and
future rights if the court has given a survivor
your current spouse must both waive the
annuity to a former spouse.
regular survivor annuity. To do this:
(2) If a court order gives a survivor annuity to a
(a) initial and complete box 4 in
former spouse, your annuity will be reduced
Section F of the SF 2801 naming
to provide it. If you elect a full or partial
survivor annuity for your current spouse (or
your current spouse;
another former spouse), your annuity will be
reduced no more than it would be reduced to
(b) complete Part 1 of SF 2801-2 and
check box b;
provide a survivor annuity equal to 55% of
your unreduced annuity.
(c) have Parts 2 and 3 of SF 2801-2
(3) If you die before your current and former
spouses, the total amount of the survivor
properly completed (i.e., spouse's
consent to insurable interest benefit
annuities paid cannot exceed 55% of your
in lieu of regular survivor annuity).
annuity. OPM must honor the terms of the
(3) If you elect an insurable interest survivor
court order before it can honor your election.
annuity for your current spouse and your
The former spouse having the court-ordered
former spouse loses entitlement before you
survivor benefit would receive an annuity
die, you may request that the reduction in
according to the terms of the court order.
your annuity to provide the insurable
(4) If the court order gives the maximum
interest annuity be converted to the regular
survivor annuity to the former spouse, your
spouse survivor annuity. (See “Survivor
widow(er) would receive no survivor
Annuity Election Changes After
annuity until the former spouse loses
Retirement,” see page 7.) Your current
entitlement. Then your widow(er) would
spouse would then be entitled to the regular
receive a survivor annuity according to your
survivor annuity. If your former spouse
election.
loses entitlement after you die, your
widow(er) can substitute the regular
(5) If the court order gives less than the
maximum survivor annuity to the former
survivor annuity for the insurable interest
survivor annuity.
spouse, your widow(er) would receive an
(4) If for any reason OPM cannot allow your
annuity no greater than the difference
insurable interest election for your current
between the court-ordered survivor annuity
spouse, your current spouse will be
and 55% of your annuity. However, if the
considered elected for a maximum regular
former spouse loses entitlement to the
survivor annuity, unless your current spouse
survivor annuity (through remarriage before
signs another SF 2801-2 consenting to less
age 55 or death), your widow(er)'s survivor
than a maximum regular survivor annuity.
annuity would be increased to the amount
you elected.
i. Voluntary Contributions and Survivor Annuity
For example, if there is a court-ordered
Election.
former spouse survivor annuity that equals
The following information applies only to employees
40% of your annuity, you elect the
who have made voluntary contributions to purchase
maximum survivor annuity for your current
additional annuity (see page 10), or who are using
spouse, and you die before the former
excess retirement deductions (see “80% Limitation on
spouse's entitlement to a survivor annuity
Basic Annuity” on page 8) as voluntary contributions.
ends, the former spouse would receive a
(1) Survivor annuity that is purchased by
survivor annuity equal to 40% of your
voluntary contributions is not subject to the
annuity and your widow(er) would receive a
spousal consent requirement discussed on
survivor annuity equal to 15% of your
page 5, nor is it subject to court orders
annuity. However, if the former spouse later
awarding survivor benefits to former
loses entitlement to the survivor annuity
spouses. Therefore, regardless of your
(through remarriage before age 55 or death),
marital status at retirement or the type of
your widow(er) would then receive a
survivor election you make for your regular
survivor annuity equal to 55% of your
annuity:
annuity.
Standard Form 2801
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Previous editions are not usable. Revised June 2013
(a) You may elect not to provide a
survivor annuity based on the
voluntary contributions, or
(b) You may name any individual you
want to receive the voluntary
contributions survivor annuity.
That is, the individual you name to
receive the voluntary contributions
survivor annuity does not need to
be the same person you name as
survivor annuitant under the
regular survivor election made in
Section F of SF 2801.
(2) If you are married and elect to provide a
regular survivor annuity for your spouse
(by checking box 1, box 2, or box 4 of
Section F on the SF 2801), your voluntary
contributions annuity will automatically be
reduced to provide an additional survivor
annuity for your spouse, unless you attach a
signed statement to your application for
retirement in which (a) you state that you do
not want to provide a survivor annuity based
on the voluntary contributions or (b) you
name another person to receive this benefit
as explained in (4) below.
(3) If you are single and elect an annuity
payable only during your lifetime or if you
are married and with your spouse's consent
elect an annuity payable only during your
lifetime (by checking box 3 of Section F on
the SF 2801), your additional annuity
purchased by voluntary contributions will
not be reduced to provide a survivor
annuity, unless you elect otherwise as
explained below.
(4) If you want to designate an individual to
receive a survivor annuity based on your
voluntary contributions, you must submit a
signed statement which names the person
who is to receive the voluntary contributions
survivor annuity. (Only one person may be
named.) The signed statement must be
attached to your application for retirement.
If you are electing a survivor annuity for a
person other than a current spouse, the
statement must include that person's full
name, date of birth, social security number,
and mailing address. (In this instance, you
must also provide proof of the person's date
of birth, such as a certified birth certificate.)
(5) The reduction in your voluntary
contributions annuity to provide a survivor
annuity based on your voluntary
contributions depends upon the difference
between your age and the age of the person
named to receive the survivor annuity as
shown in the table on page 3.
The survivor's rate is 50% of your additional
annuity after it is reduced to provide a
survivor benefit. Important: The reduction
to provide the voluntary contributions
survivor annuity will not be eliminated if the
person you elect to receive this benefit dies,
nor can you substitute another individual to
receive the benefit.
Survivor Annuity Election Changes
After Retirement
a.
You may name a new survivor or change your
election if, not later than 30 days after the date of
your first regular monthly payment, you file a new
election in writing. If the person you named to
receive a survivor annuity dies or your current
marriage ends in death, divorce or annulment, you
should write OPM, Retirement Operations Center,
Boyers, PA 16017. (Note: If your marriage to the
spouse you had at retirement continues, you must
have his or her consent to any election that does not
provide the maximum current spouse survivor
annuity.)
Your first regular monthly payment is the first
recurring annuity payment (other than an estimated
payment or an adjustment) after OPM has determined
your regular rate of annuity payable under CSRS and
has paid the annuity accrued since the time you
retired.
b.
When the 30-day period following the date of your
first regular monthly payment has passed, you cannot
change your election except under the circumstances
explained in the following paragraphs.
c.
You may change your decision not to provide a
survivor annuity for your spouse at retirement or you
may increase the survivor annuity amount for your
spouse at retirement if you request the change in
writing no later than eighteen months after the
commencing date of your annuity. You must also
pay a deposit with interest representing the difference
between the reduction for the new survivor election
and the original survivor election, plus a charge of
$245.00 for each thousand-dollar change in the
designated survivor's base. Such an election would
cancel any joint waivers made at retirement.
However, the total survivor annuity(ies) provided for
former spouses (by court order or election) and the
current spouse cannot exceed 55% of your annuity.
Note, you can make a contingent election of 55% for
your current spouse even if there is a court order.
d.
The reduction in your annuity to provide a survivor
annuity for your current spouse stops if your
marriage ends because of death, divorce, or
annulment. However, you may elect, within 2 years
after the marriage ends, to continue the reduction to
provide a former spouse survivor annuity for that
person, subject to the restrictions in paragraph j.
If you marry someone else before you make this
election, your new spouse must consent to your
election.
e.
The reduction in your annuity to provide a survivor
annuity for a former spouse ends (1) when the former
spouse dies, (2) when the former spouse remarries
before reaching age 55, or (3) under the terms of the
court order that required you to provide the survivor
annuity for the former spouse when you retired.
(Modifications of the court order issued after you
retire do not affect the former spouse annuity.) If
you and your former spouse were married for 30
years or longer, the reduction does not end.
However, if at retirement, you had elected a survivor
annuity for your current spouse (or another former
spouse), the reduction will be continued to provide
Standard Form 2801
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Previous editions are not usable. Revised June 2013
annuity for that person. If you have not previously
made an election regarding a current spouse whom
you married after retirement (or if your election
regarding a current spouse at retirement was based
on a waiver of spousal consent), you may, within 2
years after the former spouse is no longer eligible
because of remarriage before age 55 or death, elect
a reduced annuity to provide a survivor annuity for
that current spouse. This election is subject to the
restrictions given in paragraph j.
f. If you were not married at retirement, you may
elect, within 2 years after a post-retirement marriage,
a reduced annuity to provide a maximum or
less-than-maximum survivor annuity for your spouse,
subject to the restrictions given in paragraph j.
g. If you were married at retirement, that marriage ends,
and you marry again, you may elect a reduced annuity
to provide a maximum or less-than-maximum survivor
annuity for your new spouse, subject to the restrictions
given in paragraph j. Please note that the survivor
annuity elections automatically terminate upon
divorce. You must make a new election within
2 years after the divorce to provide a survivor annuity
for a former spouse. Continuing a survivor reduction,
by itself, is not a former spouse survivor election. If
you remarry the same person you were married to
at retirement and that person had previously consented
to your election of no survivor annuity, you may not
elect to provide a survivor annuity for that person
when you remarry.
h. If, at retirement, you received (by election or court
order) a reduced annuity to provide a survivor
annuity for a former spouse and you elected to
provide an insurable interest survivor annuity for
your current spouse, you may change the insurable
interest election to a regular current spouse survivor
annuity within 2 years after your former spouse loses
entitlement (because of remarriage before age 55,
death, or the terms in the court order), subject to
restrictions (1) and (2) given in paragraph j.
i. The reduction in your annuity to provide an insurable
interest survivor annuity ends if the person you
named to receive the insurable interest annuity dies
or when the person you named is your current spouse
and you change your election as explained in
paragraph h. The reduction also ends if, after you
retire, you marry the insurable interest beneficiary
and elect to provide a regular survivor annuity for
that person. If you marry someone other than the
insurable interest beneficiary after you retire and
elect to provide a regular survivor annuity for your
new spouse, you may elect to cancel the insurable
interest reduction.
j. Post-retirement survivor elections are subject to the
following restrictions:
(1) They cannot be honored to the extent that
they conflict with the terms of a qualifying
court order that requires you to provide a
survivor annuity for a former spouse.
(2) They cannot be honored if they cause
combined current and former spouse
survivor annuities to exceed 55% of
your unreduced annuity; and
(3) If, during any period after you retired, your
annuity was not reduced to provide a current
or former spouse survivor annuity, you must
pay into the retirement fund an amount
equal to the amount your annuity would
have been reduced during that period plus
6% annual interest.
k.
Insurable interest elections are not available after
retirement.
How Annuities Are Computed
The following discussion is not detailed enough to answer
every question you may have. Your agency is responsible for
giving you an annuity estimate and specific advice about your
individual circumstances.
Basic Annuity Computation — The amount of your annuity
depends primarily on your “high-3” average pay and length of
service.
Unused Sick Leave — An employee who retires with unused
sick leave will have the number of working days represented
by such leave added to the years of service for the purpose of
computing the annuity. Additional annuity earned thereby
will not be subject to the 80% limitation on basic annuity.
Days of unused sick leave may not be used in determining
average pay or length of service for annuity eligibility.
High-3 Average Pay — The “high-3” average pay is the
highest pay obtainable by averaging the rates of basic pay in
effect during any 3 consecutive years of service with each rate
weighted by the time it was in effect.
Basic Annuity Formula — For employees generally, (a)
take: 1½ percent of the “high-3” average pay and multiply the
result by 5 years of service; (b) add: 1¾ percent of the
“high-3” average pay multiplied by years of service between 5
and 10; and (c) add: 2% of the “high-3” average pay
multiplied by all service over 10 years.
Formula for Law Enforcement and Firefighter Personnel
— The basic annuity of an employee who retires under the
special provision covering law enforcement, firefighter and
nuclear materials courier personnel is 2½ percent of the
“high-3” average pay multiplied by 20 years of law
enforcement, firefighter and/or nuclear materials courier
service, plus 2% of the “high-3” average pay multiplied by all
service over 20 years.
Other Special Computations — Information concerning
other special computations, such as those for certain air traffic
controllers, customs and border protection officers, nuclear
materials couriers, Members of Congress, Congressional
employees, retirement under provisions of the Panama Canal
Treaty, etc., must be obtained from your employing agency.
80% Limitation on Basic Annuity — The basic annuity may
not be more than 80% of the employee's “high-3” average
pay. Retirement deductions withheld after the month the 80%
limitation is reached are, at separation, set aside as a special
credit. At retirement, this special credit is applied to any
unpaid deposit or redeposit. Any balance, or the entire special
credit if no deposit is due, is refundable before annuity has
been granted or may be used as voluntary contributions to
purchase additional annuity as explained below.
Standard Form 2801
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Previous editions are not usable. Revised June 2013
Guaranteed Minimum Disability Annuity — An employee
retiring before age 60 on account of total disability is
guaranteed a minimum basic annuity which amounts to the
lesser of (a) 40% of the “high-3” average pay or (b) the sum
obtained by using the basic annuity formula above, but
increasing the length of actual service by the period between
the date of the employee's separation for retirement and the
date age 60 is reached.
If the basic annuity is greater than the guaranteed minimum,
the basic annuity is paid instead. Persons receiving military
retired pay or pension or compensation from the Department
of Veterans Affairs in lieu of military retired pay are generally
not eligible for the guaranteed minimum annuity computation.
Reductions to the Basic Annuity — There are several
possible reductions to the basic annuity. These include:
a. Service You Have Not Paid For — Civilian service
during which no retirement deductions were withheld
from your salary is called “nondeduction” service.
A “deposit” is a payment to the retirement fund to
cover a period of nondeduction service. You do not
have to make a deposit if you do not wish to do so.
This can affect the amount of your monthly annuity.
However, this service is creditable for title to annuity
and may be used as needed in computing your
“high-3” average salary, even if the deposit is not
paid.
Non-Deduction Service On or After October 1, 1982
— If you have performed creditable civilian service
on or after October 1, 1982, during which no
retirement deductions were withheld and for which
you have not paid a deposit, that service will not be
included in computing your annuity. If you have
such service, you will be given an opportunity to pay
the deposit, with interest, before we complete our
action on your application. If you are eligible for and
elect an alternative annuity, the deposit will be
“deemed” paid.
Reduction for Non-Deduction Service Performed
Before October 1, 1982 — An employee who
performed creditable civilian service before October
1, 1982, during which no retirement deductions were
withheld from salary and for which no deposit has
been made will have his or her annual annuity
reduced by 10% of the amount due as deposit. The
deposit consists of the amount which would have
been withheld as retirement deductions, plus interest.
Retiring employees who want information on paying
such a deposit should attach a signed statement to
that effect to the application for retirement. If you
are eligible for and elect an alternative annuity, the
amount due as deposit for civilian service will
generally be “deemed” paid.
b. Refunded Service — Civilian service for which
retirement deductions were withheld from your
salary and later refunded to you is called “refunded”
service. A “redeposit” is a payment to the retirement
fund to cover a period of refunded service.
Generally, you do not have to make a redeposit if you
do not wish to do so. However, this can affect the
amount of your monthly annuity.
Refunded Service Which Ended On or After March 1,
1991 — You will receive no credit in the computation
of your annuity for the period of refunded service.
This usually results in a reduction in the amount of
your annuity, or, in the event of your death, your
eligible widow's (or widower's) annuity. The period
of service will be creditable for title and average
salary purposes whether or not a redeposit is made.
If you are eligible for and elect an alternative annuity,
the redeposit will be “deemed” paid.
Refunded Service Which Ended Before March 1,
1991 — If you separated from service on or after
October 28, 2009, you will receive credit in your
annuity computation for the period of refunded
service. If you do not pay the redeposit for this
service, your annuity will be permanently, actuarially
reduced because the redeposit is not paid. The
amount of the reduction will be based on factors
which will be divided into the amount of redeposit
and interest you owe at retirement. Annuities based
on separations for disability are not subject to the
actuarial reduction and any redeposit due must be
paid at retirement. If you are eligible for and elect an
alternative annuity, the redeposit will be “deemed”
paid.
c. Reduction for Unpaid Post - 1956 Military Service —
See the discussion on page 4, instructions for
completing Schedule A.
d. Reduction for Early Retirement — Unless
retirement is based on disability or under the special
provision for law enforcement, firefighter, nuclear
materials courier or customs and border protection
officer personnel, the annuity of an employee who
retires before age 55 will be reduced by 1/6 of 1%
(2% a year) for each full month, if any, under age 55.
e. Reduction for Alternative Annuity — An employee
who separates for a non-disability retirement with a
life threatening medical condition and a life
expectancy of 2 years or less is eligible to elect an
alternative annuity benefit. The employee will receive
a lump-sum payment of his or her unrefunded
retirement contributions, including post-1956 military
deposits, and a reduced monthly annuity. Deposits and
redeposits that are “deemed” paid are not included as
part of the lump-sum payment. The amount of the
reduction in annuity is based on the employee's age at
retirement and amount of retirement contributions.
Employees retiring on disability or who have a former
spouse who is entitled by court order to receive a
portion of the employee's annuity or a survivor
annuity cannot elect an alternative annuity. Married
employees must obtain their current spouse's consent
in order to elect an alternative annuity.
f. Reduction for Survivor Annuity — This reduction is
explained under Section F - Annuity Election starting
on page 3.
Standard Form 2801
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Previous editions are not usable. Revised June 2013
Additional Annuity (Voluntary Contributions) — An
employee who, in addition to the amounts withheld from
salary, has made voluntary contributions to the retirement
fund will be paid, in addition to the regular annuity, $7.00 per
year, plus $0.20 for each full year the individual is over age
55 at retirement, for each $100.00 in his or her voluntary
contributions account. If, with respect to voluntary
contributions, an employee elects a survivor annuity, the
additional annuity purchased will be reduced based on the
difference between the annuitant's age and the survivor's age
as shown in the table on page 3. The survivor's annuity will be
50% of the employee's additional reduced annuity. Note: The
additional annuity purchased by voluntary contributions is not
increased by cost-of-living adjustments.
Cost-of-Living Increases
1. Limitation on amount of increase. An annuity may
not be increased by a cost-of-living adjustment to an
amount that exceeds the greater of (a) the maximum
pay for a GS-15 thirty days before the effective date
of the adjustment or (b) the final pay (or average pay
if higher) of the retired employee, increased by the
overall annual percentage adjustments (compounded)
in General Schedule rates of pay since the employee's
retirement.
2. Determination of amount of increase and effective
date. Cost-of-living increases are effective on
December 1 and are payable in the January annuity
payment. They are determined by the percentage
increase in the average Consumer Price Index for the
"base quarter" of the year in which they are effective
over the "base quarter" of the preceding year in
which an increase occurred. The “base quarter" is
July, August, and September. The first cost-of-living
increase you receive will be prorated to reflect the
number of months you are on the retirement rolls
before the increase is effective.
Payment and Accrual of Annuity
All annuities are payable in monthly installments on the first
business day of the month following the one for which the
annuity has accrued. All annuities are adjusted to the next
lower dollar.
The commencing date of most annuities is the first day of the
month after pay ceases and all other requirements for title to
annuity are met. There are three exceptions, however:
(1) disability annuities, (2) annuities based on involuntary
separations, and (3) annuities based on voluntary retirement
of employees who are in pay status for three days or less in
the month of retirement. In these three instances, annuities
commence no later than the day after pay ceases and all other
requirements for title to annuity are met.
Filing Your Application
Submit the completed application to your agency. Your
agency must then complete the Agency Checklist of Immediate
Retirement Procedures (SF 2801 - Schedule D) and Certified
Summary of Federal Service (SF 2801-1) which are included
in this package. These forms were included in this package so
that you would have an opportunity to review and become
familiar with the type of information and procedures your
agency will need to process your application. After you
submit your application, your agency will complete the
SF 2801-1 and return it to you for your review and signature.
If you are applying for disability retirement, you and your
agency will also need to complete SF 3112. (Be sure to ask
your employing agency what documentation and evidence are
necessary if you are applying for disability retirement.)
Important: You and your employing agency are jointly
responsible for the completeness and correctness of the Certified
Summary of Federal Service (SF 2801-1). You should review it
carefully before signing it. If you have already signed a
summary (for example, during pre-retirement counseling), ask
your agency to let you review it again. Any errors, omissions,
or discrepancies will delay the processing of your application
and may result in incomplete credit for service in the initial
adjudication of your application.
What Happens After You File Your
Retirement Application
1.
Your Employing Office
Your employing office will close out your records,
using the Agency Checklist to assure that all
necessary steps are taken. When this process (which
includes paying you any unpaid compensation, such
as for unpaid annual leave) has been completed, the
agency will forward your application and records to
OPM.
2. OPM Acknowledgment
Within a few days after receiving your application
OPM will send you an acknowledgment. This
acknowledgment will show your claim number,
which will begin with the letters “CSA.” This
number will be very important to you as an annuitant
because you will need to refer to it any time you
write or call us in connection with your annuity.
Important: OPM cannot begin the processing of
your application for retirement until we receive your
application and retirement records from your agency.
If you need to contact OPM about your application
before you receive your retirement (CSA) claim
number, contact your former payroll office. Your
former payroll office can tell you if your application
and records were sent to OPM. If the records were
sent, you should provide OPM with the payroll office
number and the number and date of the Register of
Separations and Transfers on which your retirement
package was sent. Only your payroll office can
provide this information. Do not contact OPM
unless your retirement package has been sent to us.
Management
and Payroll Office Payroll Office
U.S. OfficeU.S. Office ofof PersonnelPersonnel Managemen
CSRS/FERS HandbookCSRS/FERS Handbook forfor PersonnelPersonnel an
Standard Form 2801
NSN 7540-00-634-4250NSN 7540-00-634-4250
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Previous editions are not usable. Revised June 2013
3. Interim Annuity Payments 6. After Your Application Is Processed
The next action OPM takes is a preliminary review of When we finish processing your application, we will
the records available at the time your application is send you a booklet explaining your benefits and any
received. If your entitlement to annuity is clear at monthly survivor benefits payable after your death.
this point, OPM may authorize interim annuity The booklet contains information you will need after
payments as a means of preventing undue financial you retire, including how to contact OPM to make
hardship while we process your application. These various changes (tax withholding, address, health
interim payments may be lower than your actual benefits, etc.).
annuity rate. When interim payments are authorized,
you will receive a notice showing the amount of your
payments.
What To Do If Your Address Changes
Before Processing Is Completed
4. Alternative Annuity (Lump-Sum Refund)
Employees who separate for non-disability
retirement, have a life threatening medical condition
and a life expectancy of 2 years or less are eligible to
If your address changes before you receive your claim
number, first contact your agency to find out if your
application has been forwarded to OPM.
elect an “alternative” annuity (lump-sum refund of
If your agency has forwarded your application or if you have
retirement contributions with a reduced monthly
received your claim number, you can telephone, use email, or
benefit). OPM will send you specific information
write to report your new address. If you know your claim
about this election during the processing of your
number, please refer to it in any correspondence. If you do
application. If you are retiring because of a
not yet have a claim number, please give your name, Social
disability or if you have a former spouse entitled to
Security number, date of birth, the date of retirement, and the
court-ordered benefits, you are not eligible to elect
agency you retired from.
an alternative annuity.
You can call OPM at 1-888-767-6738. If you use TTY
5. Disability and Special Retirement Applications
Applications for disability retirement and special
retirements are processed differently. For disability
retirements, your agency will forward your
application, evidence supporting your claim of
disability, and preliminary records to OPM for
disability determination based on review of both
medical and non-medical evidence. Interim annuity
equipment, call 1-855-887-4957. The Internet address is
www.opm.gov/retirement-services. The email address is
retire@opm.gov. If you prefer to write to us, you should
report your new address to:
U. S. Office of Personnel Management
Attn: Change of Address
P. O. Box 440
Boyers, PA 16017-0440
payments can be authorized only if and after the
In addition, you should notify the Postal Service of your
disability has been approved and your last day in a
forwarding address.
pay status is known to OPM. For law enforcement,
firefighter, air traffic controllers, customs and border
protection officers, and nuclear materials couriers,
your agency will forward evidence concerning your
entitlement to the special provisions. Interim annuity
payments can be authorized only if and after OPM
has verified your entitlement to the benefit.
Privacy Act Statement
Solicitation of this information is authorized by the Civil Service Retirement law, the Federal Employees' Group Life Insurance law, and the Federal Employees
Health Benefits law (Chapters 83, 87, and 89, of title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your
application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a uniquely identifiable
claim file. The 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 in order 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. Furnishing the Social Security number, as well as other data, is voluntary, but failure to do so may delay or prevent action on your
application. Information you provide about your unmarried dependent children may be used to expedite their claims after you die; however, your failure to supply
such information will not affect any future rights they may have to benefits.
U.S. Office of Personnel Management Standard Form 2801
CSRS/FERS Handbook for Personnel and Payroll Offices
NSN 7540-00-634-4250
-11-
Revised June 2013
Previous editions are not usable.
See Privacy Act
Application for Immediate Retirement
Information on
Civil Service Retirement System (CSRS)
Instruction Sheet
Section A - Identifying Information
3.
2.
4b.4a.
Home Email address
Are you a citizen of the United States of America?
8.
Yes Yes (Ask your employing office about other documents you must submit)
Name (last, first, middle) 1. List all other names you have used
Address (number, street, city, state, ZIP code)
Best time to reach you Daytime area code and telephone number after retirement
4c.
7.
No No
Is this an application for disability retirement?
4d. FAX number
5. Date of birth (mm/dd/yyyy)
( )
All social security numbers you have
used.
6.
Section B - Federal Service
1. Department or agency from which you are retiring (Include bureau or division) 2. Date of final separation (mm/dd/yyyy)
3. Title of position from which you are
retiring
3a. Your pay plan and occupational series
1a. Address and ZIP code
( )
4. Have you performed active honorable service in the Armed Forces or other uniformed services of the United States (see SF 2801A for definitions)?
Yes (Complete Schedule A and attach it to this form) No
5. Are you receiving or have you applied for military retired pay? (Note: If you later become entitled to military retired pay, you must notify OPM.)
Yes (Complete Schedule B and attach it to this form) No
Section C - Other Claim Information
1. Are you receiving or have you applied for (or received within the past 2 years) workers' compensation from the Department of Labor because of a job-related illness
or injury?
Yes (Complete Schedule C and attach it to this form)
No
2. Have you previously filed any application under the Civil Service Retirement System or Federal Employees Retirement System (for retirement, refund, etc.)?
Yes (Complete items 2a and 2b below.)
No
2a. Type of application
Retirement
Refund
Return of excess deductions
Deposit or redeposit
Voluntary contributions
2b. Claim number(s)
See the pamphlet SF 2801A, Applying for Immediate Retirement Under the Civil Service Retirement System,
Section D - Insurance Information
for information.
1. Are you eligible to continue Federal Employees Health Benefits coverage as a
retiree?
Yes No
2. Does a court or administrative order require that you provide health benefits
coverage for one or more children?
No Yes (Attach a copy of the order.)
3. Are you eligible to continue Federal Employees' Group Life Insurance coverage as a retiree?
Yes No
4. Are you enrolled in the Federal Dental and Vision Insurance Program (FEDVIP)? 5. Are you currently enrolled in the Federal Long Term Care Insurance Program
(FLTCIP)?
Your coverage will automatically continue into retirement as long as You will automatically continue your coverage into retirement, as
Yes Yes
you continue to pay applicable premiums.Until work on your annuity long as you continue to pay applicable premiums. If you are
is completed, you may receive bills from BENEFEDS. You must pay currently paying FLTCIP premiums by agency payroll deduction,
these bills in order to keep your FEDVIP coverage. After work on you must arrange to pay premiums, either by deductions from your
your annuity is completed, BENEFEDS will automatically begin annuity, through automatic bank debit, or direct bill. Please call
deducting from your annuity to pay future premiums. If you have LTC Partners at 1-800-LTC-FEDS (1-800-582-3337) to make these
questions, please contact BENEFEDS at 1-877-888-3337. arrangements.
If you retire on immediate annuity, you can enroll in FEDVIP during
No No
any Federal Benefits Open Season.
Section E - Marital Information (All applicants must complete questions 1 and 2 below.)
1. Are you married now? (A marriage exists until ended by death, divorce, or annulment. You must notify the Office of Personnel Management if this marriage ends.)
Yes (Complete items 1a - 1f and attach a copy of your marriage certificate) No (Go to item 2)
1a. Spouse's name (last, first, middle) 1b. Spouse's date of birth (mm/dd/yyyy) 1c. Spouse's social security number(s)
1d. Place of marriage (city, state) 1e. Date of marriage (mm/dd/yyyy) 1f. Marriage performed by:
Clergyman or Justice of Peace
Other (explain):
2. Do you have a living former spouse(s) from whom you were divorced on or after May 7, 1985, and to whom a court order gives a survivor annuity or, awards a portion of
your retirement benefit based on your Federal employment?
Yes (Attach a certified copy of the court order[s] and any amendments.) No
U.S. Office of Personnel Management Standard Form 2801
CSRS/FERS Handbook for Personnel and Payroll Offices
2801-111
Revised June 2013
NSN 7540-00-634-4250 Previous editions are not usable.
Section F - Annuity Election
Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested. Read the attached
information on pages 2 through 5 and the explanations below and consider your election carefully. No change will be permitted after your annuity is granted
except as explained on pages 7 and 8 of the attached instructions. If you are married at retirement, the law provides an annuity with full survivor benefits for
your spouse unless your spouse consents to your election not to provide maximum survivor benefits. An election for your spouse ends if your marriage ends by
death, divorce, or annulment.
I choose a reduced annuity with maximum survivor annuity (equal to 55% of my basic annuity) for my spouse named in Section
E. 1a. If you are married at retirement, you will receive this type of annuity unless your spouse consents to your election not to
provide maximum survivor benefits. If your marriage ends by death, divorce, or annulment, this election terminates and you must
1.
Initials
notify the Office of Personnel Management.
2.
Initials
I choose a reduced annuity with a partial survivor annuity (equal to 55% of $____________________ a year)
for my spouse named in Section E. 1a. If you choose this option, the amount you enter must be less than your annual annuity.
You must have your spouse's consent. Complete SF 2801-2, Spouse's Consent to Survivor Election, and attach it to your application.
If your marriage ends by death, divorce, or annulment, this election terminates and you must notify the Office of Personnel
Management.
I choose an annuity payable only during my lifetime. If you are married at retirement, you cannot choose this type of annuity
without your spouse's consent. No survivor annuity will be paid to your spouse after your death if he or she consents to this
election and any health benefits will cease. In addition, your spouse will not be eligible to enroll in the Federal Long Term Care
3.
Initials
Insurance Program, if he/she is not enrolled at the time of your death. If you are married and elect this type of annuity, complete
SF 2801-2, Spouse's Consent to Survivor Election, and attach it to your application.
I choose a reduced annuity with survivor annuity for the person named below who has an insurable interest in me. You must be
healthy and willing to provide medical evidence if you choose this type of annuity. (Disability annuitants are not eligible to choose
this type of annuity.) If you are married and elect this type of annuity, complete SF 2801-2, Spouse's Consent to Survivor Election,
4.
Initials
and attach it to your application. NOTE: This election is not included in determining the 55% maximum for the combined benefit
elected for a spouse and former spouse in box 5.
Name of person with insurable interest Relationship to you Date of birth (mm/dd/yyyy) Social security number
5.
Initials
I choose a reduced annuity with survivor annuity for my former spouse(s) or for my spouse and former spouse(s) shown below.
You must attach: (1) Copies of divorce decrees for all former spouses for whom you elect to provide a survivor annuity. (2) If you
are married, attach a completed SF 2801-2, Spouse's Consent to Survivor Election. You cannot choose this option and provide a
maximum survivor annuity for your spouse (Box 1). An election for a former spouse ends if your former spouse dies or remarries
before age 55, unless you were married for 30 years or longer. If one of these events occurs, this election terminates and you must
notify the Office of Personnel Management.
Name and address of current spouse
Survivor annuity equal
to _______________%
of my annuity
Name and address of former spouse Date of marriage
(mm/dd/yyyy)
Date of divorce
(mm/dd/yyyy)
Survivor annuity equal
to _______________%
of my annuity
Date of birth
(mm/dd/yyyy)
Social security number
Name and address of former spouse Date of marriage
(mm/dd/yyyy)
Date of divorce
(mm/dd/yyyy)
Survivor annuity equal
to _______________%
of my annuity
Date of birth
(mm/dd/yyyy)
Social security number
Total (cannot exceed 55% of your unreduced annuity)
_______________%
Section G (Optional) - Information About Your Unmarried Dependent Children
1.
Dependent child's name
(first, middle, last)
2.
Date of birth
(mm/dd/yyyy)
Disabled
( )
3.
9
1.
Dependent child's name
(first, middle, last)
2.
Date of birth
(mm/dd/yyyy)
Disabled
( )
3.
9
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices
NSN 7540-00-634-4250
2801-111
Standard Form 2801
Revised June 2013
Previous editions are not usable.
0
Section H - Direct Deposit/Direct Express and Tax Withholding Information
Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided
by the Department of the Treasury. See SF 2801A for additional information. This does not apply to you if your permanent payment address is outside
the United States in a country not accessible via Direct Deposit/Direct Express.
1. Select one of the following:
Please send my annuity payments to my checking or savings account. (Go to item 2.)
Please send my annuity payment(s) to my Direct Express debit card. (Go to item 4.)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit. (Go to item 4.)
You may obtain this number by calling your bank, credit union, or savings institution.
This number is very important. We cannot pay by Direct Deposit without it.
Section I - Applicant's Certification
Warning
Any intentionally false statement in this
application 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)
I hereby certify that all statements made in this application are true
to the best of my knowledge and belief.
Account number3.
Checking Savings
Name and address of the financial institution 3c.
Telephone number of your financial institution (including area code) 3b.
Do you want Federal income tax withheld from your annuity
payments?
4.
Yes (Go to item 4a.)
No (Go to Section I.)
Yes (Attach a copy of W-4 form on file with your employing agency.)
No (Attach a new W-4 form; otherwise, withholding will be at the rate for married
with 3 exemptions.)
Financial institution routing number 2.
What kind of account is this? 3a.
( )
3d.
Special Note: If you prefer, you may attach a cancelled personal check
that shows the information requested above, instead of filling in the
requested financial institution information. If you attach your personal
check, it is especially important that you contact your bank, credit union,
or savings institution to confirm that the information on the check is the
correct information for direct deposit. (Some institutions, especially credit
unions, use different routing numbers on checks.)
Do you want Federal income tax withheld at the rate currently being withheld from your
salary?
4a.
Date (mm/dd/yyyy)Signature (Do not print)
Applicant's Checklist
Military Service - If you completed Schedule A, did you attach a copy of your discharge certificate or other certificate of active
military service?
2.
Military Service - If you answered "yes" to Section B, Item 4, did you attach Schedule A? 1.
This checklist is provided to help you be certain you have attached all necessary documentation and to help your employing office be
certain it forwards all of your retirement documentation to the Office of Personnel Management.
Military Retired Pay - If you answered "yes" to Section B, item 5, did you attach Schedule B? 3.
Military Retired Pay - If you completed Schedule B and answered "yes" to item 2 or 3, did you attach a copy of award or other
documentation of the type of mili
tary retired pay you are receiving?
4.
Military Retired Pay - If you completed Schedule B and answered "yes" to item 4, did you attach a copy of your request for
waiver and a copy of the military finance office's acknowledgment or approval of your request for waiver (if applicable)?
5.
6.
No
Life Insurance - If you answered "yes" to Section D, item 3, did you attach SF 2818, Continuation of Life Insurance Coverage
As an Annuitant or Compensationer?
7.
OWCP - If you answered "yes" to Section C, item 1 did you attach Schedule C? 8.
Tax - If you want to elect a Federal Income Tax withholding rate, did you attach a W-4 form?
9.
Not
Applicable
Survivor Election - If you are married and did not initial box 1 of Section F, did you attach SF 2801-2, Spouse's Consent
to Survivor Election?
Court or Administrative Order(s) - If you answered "yes" to Section D, item 2, and/or "yes" to Section E, item 2 did you attach a
copy of the order(s)?
10.
Yes
U.S. Office of Personnel Management Standard Form 2801
CSRS/FERS Handbook for Personnel and Payroll Offices Revised June 2013
NSN 7540-00-634-4250 Previous editions are not usable.
Schedules A, B and C
Name (last, first, middle) 1. Date of birth (mm/dd/yyyy)2. 3. Social security number
Schedule A - Military Service Information
1. If you have performed active honorable service in the United States Armed Forces or other uniformed services, complete 1a - d below and attach a copy of your discharge
certificate or other certificate of active military service. Include active duty for the National Guard.
a.
Branch of service Serial number
b.
Dates of active duty
c.
Last grade or
rank
d.
From (mm/dd/yyyy) To (mm/dd/yyyy)
2. If any of your military service occurred on or after January 1, 1957, have you paid a deposit to your agency for this
service? (You must pay this deposit to your agency. You cannot pay OPM after you retire. See Schedule A on page 4
of the instructions for the effect on your annuity if the deposit is not paid.)
Yes No
Schedule B - Military Retired Pay
If you are receving or have applied for military retired or retainer pay (including disability retired pay), complete items 1 - 4 below.
Are you receiving or have you ever applied for military retired or retainer pay?
(Answer "yes" if you are receiving payments from the Department of Veterans
Affairs instead of military retired pay.)
1.
Yes No
Was your military retired or retainer pay awarded for reserve service under
Chapter 1223, title 10, U.S. Code, Sections 12731 through 12739 (formerly
Chapter 67, title 10)?
2.
Yes (Attach a copy of notice of award.) No
Was your military retired pay or retainer pay awarded for a disability incurred
in combat?
3.
Yes (Attach a copy of notice of
award.)
No
Are you waiving your military retired or retainer pay in order to receive credit
for military service for CSRS retirement benefits?
4.
NoYes (Attach a copy of your request for
waiver and a copy of military finance
office's acknowledgment or approval
of your request for waiver.)
Schedule C - Federal Employees' Compensation Information
1. Are you receiving or have you received workers' compensation from the Office of Workers' Compensation Programs (OWCP), Department of Labor, because of a job-related
illness or injury within the last 2 years?
Yes (complete items 1a - c below) No (go to question 2)
Compensation claim number
a. b.
Benefit received
c.
Type of benefit
From (mm/dd/yyyy) To (mm/dd/yyyy)
Scheduled award
Total or partial disability compensation
Scheduled award
Total or partial disability compensation
2.
If you have applied for workers' compensation (other than as listed in item 1a above) but are not receiving benefits, check reason below and give the information requested.
a. Awaiting OWCP decision b. Claim denied
Compensation claim number Compensation claim number Date claim denied (mm/dd/yyyy)
3. Except for scheduled compensation awards, workers' compensation and CSRS retirement benefits cannot be paid for the same period of time. Please complete the
information below regarding your claim. You must complete this section.
a. Do you agree to notify us promptly if the status of your workers' compensation claim changes?
Yes No
b. Do you authorize the Office of Personnel Management and/or the Office of Workers' Compensation Programs (OWCP) to collect any overpayment if we later find you
are not eligible for both compensation and annuity payments covering the same period of time?
Yes No
Applicant's Certification
I certify that all statements made on
these schedules are true to the best
of my knowledge and belief.
Signature (do not print) Date (mm/dd/yyyy)
U.S. Office of Personnel Management Standard Form 2801
CSRS/FERS Handbook for Personnel and Payroll Offices Revised June 2013
NSN 7540-00-634-4250 Previous editions are not usable.
Spouse's Consent to Survivor Election
Instructions: If you are married and you do not elect a reduced annuity to provide a maximum survivor annuity for your current spouse,
complete Part 1. Have your spouse complete Part 2. Part 2 must be completed in the presence of a Notary Public or other person authorized to
administer oaths. The person administering oaths must complete Part 3.
Part 1 - To Be Completed by the Retiring Employee
Name (last, first, middle) Date of birth (mm/dd/yyyy) Social security number
I have elected: (Mark the box(es) which describe the election you have made with regard to your current spouse. For example, a married employee who only
elects a survivor annuity for a former spouse, must also check boxes “a” and “d”.)
a. No regular or insurable interest survivor annuity for my current spouse. I understand that:
•
No survivor annuity will be paid to my spouse after my death,
•
His/her Federal Employees Health Benefits coverage based on my Federal employment will terminate upon my death, and
•
He/she will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) after my death.
d. A survivor annuity for my former spouse __________________________________________________ equal to _____________% of my annuity.
c. A partial survivor annuity for my current spouse equal to 55% of $_________________________ a year.
b. An insurable interest survivor annuity for my current spouse, but no regular survivor annuity for my current spouse. (I have completed Section F,
item 4 on my Standard Form 2801 naming my current spouse.)
(name of former spouse)
Part 2 - To Be Completed by the Current Spouse of the Retiring Employee
General Information: The law requires that a retiring, married employee The current spouse may, therefore, receive a smaller annuity than elected
must elect to provide a survivor annuity for a current spouse, unless the or none at all, unless the former spouse loses eligibility for the court-
current spouse consents to some other election by signing this form. ordered survivor annuity.
A court order which requires a retiring employee to provide a survivor Important: If the current spouse consents to an election to provide no
annuity for a former spouse is not an election and spousal consent is not survivor annuity or a partial survivor annuity and is later divorced from the
required. In other words, such a court order does not require a current spouse retired employee, the retired employee may not then elect (nor can OPM
to waive the right to a survivor annuity for the current spouse, even though honor a court order) to provide a former spouse annuity which exceeds the
the Office of Personnel Management must honor the terms of the court order amount elected at retirement for that spouse. This also applies if the parties
before it can honor the election for the current spouse. remarry.
I freely consent to the survivor annuity election described in Part 1. I understand that if my spouse elected no regular or insurable interest
survivor annuity in Part 1 above, after my spouse dies I will not receive a survivor annuity, my Federal Employees Health Benefits
coverage will terminate when my spouse dies, and I will not be eligible to enroll in the Federal Long Term Care Insurance Program
(FLTCIP) if I am not already enrolled before my spouse's death. I also understand that my consent is final (not revocable).
Name (type or print) Signature (do not print) Date (mm/dd/yyyy)
Part 3 - To Be Completed by a Notary Public or Other Person Authorized to Administer Oaths
I certify that the person named in Part 2 presented identification (or was known) to me, gave consent, signed or marked this form and
acknowledged that the consent was freely given in my presence on this
the __________ day of _________________________, __________, at _______________________________________________________.
(Month) (Year) (City and State)
(Seal of Notary Public or witnessing authority of person authorized to administer oaths)
(Seal)
Signature (do not print)
Expiration date (mm/dd/yyyy) of commission, if Notary Public
Privacy Act Statement
Public Law 98-615, which establishes the spousal consent requirement, authorizes solicitation of this information. The data furnished will be used to determine the type of
annuity awarded. The 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 in order 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 use of the Social Security number. Failure to
provide information may delay or prevent action on your application.
U.S. Office of Personnel Management Standard Form 2801-2
CSRS/FERS Handbook for Personnel and Payroll Offices
2801-111
Revised June 2013
NSN 7540-00-634-4250 Previous editions are not usable.
Certified Summary of Federal Service
Civil Service Retirement System
Information for Agency
1. A certified copy of this form must accompany the employee's
Application for Immediate Retirement (SF 2801) or an Application
for Death Benefits (SF 2800) for a deceased employee if a survivor
annuity appears to be payable.
2. This form may also be used:
• for retirement counseling purposes
• to respond to an employee's request for a record of creditable
service
1. Name (last, first, middle)
7. Service computation date for
retirement purposes
Pay plan and occupational series 8.
9a. Does the applicant receive military retired pay? 9b. If Yes, has the applicant waived military retired pay to credit military service for
civil service retirement?
Yes (Attach a copy of the applicant's military retired pay order,
if available, and complete 9b.)
Yes (Attach a copy of the military finance center's letter to the
employee accepting waiver, if available.)
No No (Includes cases where a waiver is not necessary.)
4. List all other names used (maiden name, AKA, spelling variants)
3. See the CSRS and FERS Handbook for Personnel and Payroll
Offices for detailed instructions for completion and disposition of
this form.
Instructions for the Employee
1. Your employing office will complete and certify this form for you.
2. Review this form carefully. Be sure it contains all of your service.
3. Complete Section E, Employee's Certification, and return the form
Section A - Identification
to your employing office.
2. Date of birth (mm/dd/yyyy)
5. Other birth dates used
3. Social security number(s)
6. Military serial number
Section B - Verified Service History Documented in Official Records
Federal agency or
military service branch
Appointment, separation, or conversion
dates for civilian and active honorable
military service
Name of retirement
system*
(e.g., CSRS,
CSRS Offset, etc.)
Remarks and non-creditable time
(Indicate if service is part-time. If service was WAE or
intermittent, show the number of days or hours worked.)
From (mm/dd/yyyy) To (mm/dd/yyyy)
*Give details of creditable civilian service not subject to retirement deductions in Section C.
U.S. Office of Personnel Management Standard Form 2801-1
CSRS/FERS Handbook for Personnel and Payroll Offices
2801-111
Revised June 2013
NSN 7540-00-634-4250 Previous editions are not usable.
2801-111
This information is required to compute the portion of annuity based on such service.
Detail below (1) any period of Federal civilian service subject to "FICA" deductions and (2) any other Federal civilian service not subject to a Federal
employee (or DC Government) retirement system. If total basic salary earned for any such period of service is known, you may make a summary entry on the
right hand side below. Otherwise, show each change affecting basic salary during the period of service. Show part-time tour of duty, if applicable. If part-time
service is after April 6, 1986, also provide total number of hours employee worked during the period and show what a full-time tour of duty would be.
I certify that the information on this form accurately reflects verified information contained in official personnel and/or payroll records in the custody of
this agency and that, if retiring, the employee has sufficient service for an immediate annuity.
Section C - Details of Civilian Service Not Subject to Contributory Retirement System for Civilian
Federal Employees
Nature of action
(Appt., pro.,
res., etc.)
Effective date
(mm/dd/yyyy)
Basic
salary rate
Salary basis
(per annum,
per hour,
WAE, etc.)
Leave
without pay
If basic salary actually earned is available,
make summary entry below:
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Total earned
Section D - Agency Certification
Signature of Authorized Agency Human Resources Official Agency name and address, including ZIP Code, area code and telephone number,
FAX number, and email address
Official Title
Section E - Employee's Certification
The service listed is complete.
I have additional service. (If you claim additional service, attach signed statement(s) giving dates, positions, titles and locations of employment,
including agency, bureau, and division. Claimed service cannot be credited for retirement until it has been verified. This includes unverified service
listed on SF 144, Statement of Prior Federal Civilian and Military Service, or similar affidavit.)
Date (mm/dd/yyyy)
Note: If you have performed Federal civilian service subject to social security deductions (FICA) or not subject to retirement deductions, be sure that
your agency has correctly completed Section C above. If you have active military service on or after January 1, 1957, for which you have not
made a deposit, be sure to read Schedule A on page 4 of the “Instructions” for Completing Application for Immediate Retirement for information
on how this affects your annuity. You cannot change your decision after you retire.
Date (mm/dd/yyyy)Signature
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices
NSN 7540-00-634-4250
Reverse of Standard Form 2801-1
Revised June 2013
Previous editions are not usable.
Agency Checklist of Immediate Retirement Procedures
Civil Service Retirement System
Section A - Employing Office Checklist: To be completed by office maintaining Official Personnel Folder (OPF).
Name (last, first, middle) 1. Date of birth (mm/dd/yyyy)2. Social security number3.
Type of retirement 4. Special provisions (Check any applicable) 5.
Age (Mandatory)
Optional (Other than “Early Optional”)
Early Optional (Requires OPM or Legislative Authority)
Discontinued Service (Involuntary separation)
Disability
Law enforcement/firefighter
Air traffic controller
Other (Specify below)
6. Is the applicant eligible to continue FEHB coverage in retirement?
Yes, enrollment code: ________________ No, give reason:
9.
7.
8.
If the annuity is not for disability, are the following documents attached?
a. All SF 2809's* in the applicant's OPF
b. All SF 2810's* in applicant's OPF
c. SF 2821*
d. All SF 2817's*, SF 176's*, SF 176T's*
e. SF 2818*
f. All SF 54's* and SF 2823's* in the applicant's OPF
Yes Sent to
OWCP
Not
Applicable
If post-1956 military service is involved and deposit is not made, was applicant counseled about the effects of not paying the deposit?
Attach OPM Form 1515*
Is the applicant eligible to continue FEGLI coverage in retirement?
Yes, complete 7a.
No, give reason:
The applicant can continue Basic Life insurance and the following options: 7a.
No optional insurance
Option A - Standard
Option B - Additional with the following multiples:
1 2 3 4 5
Option C - Family with the following multiples:
Are the following documents attached or actions taken? Indicate by an “X” for each item.
1 2 3 4 5
a. SF 2801*
b. All documents applicant shows attached to SF 2801
c. If applicant is married and elects less than the maximum survivor benefit, SF 2801-2*
d. SF 2801-1*
e.
If applicant served in the military, or applied for military retired pay or DOVA benefits in lieu of military retired pay, or applied for
OWCP benefits, Schedules A, B, C of SF 2801
f. If applicant has military service, DD 214 or its equivalent, if available
g. If applicant wants a refund of military service deposit because he/she does not want to waive military retired pay, SF 2802*
h. If applicant wants to waive military retired pay, copy of waiver request and response from Military Retired Pay Center, if available
i.
Yes Not
Applicable
j.
If discontinued service retirement, documentation specified in Chapter 44, CSRS and FERS Handbook for Personnel and Payroll Offices,
including OPM Form 1510* and attachments
If early optional retirement, enter OPM authority or Public Law number here k.
l.
If law enforcement/firefighter, customs and border protection officers, or nuclear materials courier, agency certification if the applicant is
eligible for a special computation
m. If OPM has approved disability retirement, a copy of the approval notice and checklist
n. If employee has applied for compensation benefits, OWCP award, if available
o. Agency estimates of annuity
p.
If divorced on/after 5/7/1985, and former spouse is awarded a survivor annuity or a portion of retirement, a copy of the divorce decree,
court order, and property settlement agreement.
10. If retirement is for disability, is the employee's disability documentation specified in SF 3112* attached?
Yes No, explain:
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices
*See page 3 for titles of forms referred to above.
NSN 7540-00-634-4250
-1-
Previous editions are not usable.
Standard Form 2801- Schedule D
Revised June 2013
11. List any documents attached which are not listed on the front of this checklist.
12. Certification by the Chief Human Resources Officer or Designee
I certify that the above accurately reflects verified information in official records and that the applicant has sufficient service to be entitled to an
annuity. I further certify that all required documentation in support of this application is attached, accurate, and complete.
Signature
Official Title
Person to contact for further information
Address
Submitting Office Number (SON)
Telephone number, FAX number, and email address
Offenses Barring Annuity Payments: Public Law 87-299 prohibits payment of annuity to persons who have committed specified offenses involving the
national security of the United States. Employing agencies are responsible for submitting all pertinent information to the Office of Personnel Management,
Retirement Services, in any case when this law possibly applies.
Section B - Payroll Office Checklist: To be completed by the office maintaining the Individual Retirement Record
(SF 2806)
If the appropriate response to a question is “Not Applicable,” leave blank.
Important: The SF 2806 must be closed out and received by OPM within 30 days after the employee's date of separation.
If applicant is continuing life insurance into retirement, is the SF 2821 with Payroll certifying signature attached?
1.
2.
3.
4.
5.
6.
7.
7a.
8.
8a.
9.
10.
Yes No*
Does the SF 2806 for the applicant named in Section A contain all information necessary to comply with OPM instructions for
maintaining the Individual Retirement Record?
Is applicant's sick leave balance shown on SF 2806?
Is applicant's last day in pay status shown on SF 2806?
Is the applicant's health benefits status posted on SF 2806?
If this is a preliminary SF 2806 for disability retirement, is applicant's life insurance status posted?
Has applicant made a military service deposit with your agency?
If "yes," is the SF 2806 for the deposit attached?
Does the applicant have any part-time service on or after April 7, 1986?
If "yes," is the number of hours in each scheduled tour of duty and the date of each change in tour of duty posted on the SF 2806 or
SF 2806-1 (including changes to full-time and intermittent status)? Also, show what a full-time tour of duty would be, total number
of hours actually worked, and what total number of hours would have been if employee had always worked full-time.
If the applicant is a Postal Service employee, are postal earnings for non-deduction service shown on SF 2806?
Disposition of SF 2806:
SF 2806 and Register of Separations and Transfers (SF 2807) are attached.
If SF 2806 was already forwarded, provide the following:
Forwarded to:
SF 2807 Number:
Date (mm/dd/yyyy) of SF 2807:
*11. Explain any "No" responses here:
12. Certification by the Chief Payroll Officer or Designee
I certify that the above reflects official records maintained by this office.
Signature Telephone number, FAX number, and email address
Payroll Office Number Date (mm/dd/yyyy)
U.S. Office of Personnel Management Standard Form 2801- Schedule D
CSRS/FERS Handbook for Personnel and Payroll Offices Revised June 2013
NSN 7540-00-634-4250
-2-
Previous editions are not usable.
Section C - How to Process Open Season Health Benefits Changes When Employees Retire Before the
Effective Date of the Open Season Change:
a. If the employee is retiring before the effective date of an Open Season change, the Human Resources office should have the employee
complete the Open Season SF 2809 and have the authorized agency official initial and date Part G to show that the Open Season
registration was timely submitted. The name of the losing installation and the signature of its certifying officer should not appear on the
SF 2809. Attach the unprocessed SF 2809 to other health benefits documents and the SF 2806 when they are submitted to OPM.
b. If an Open Season change has already been processed, but the employee unexpectedly retires before the effective date of the change, the
losing office should void all Open Season forms and transfer the existing enrollment (if any) to the gaining office (OPM). Tell the
employee that the Open Season change has been voided and, if possible, have the employee complete a new SF 2809 and handle it as
stated in a. above. If it is impossible to make this action quickly, notify OPM that the employee's Open Season change, which was timely
filed, has been voided, and that a new Open Season SF 2809 will be sent to OPM. For further information, refer to the Federal Employees
Health Benefits Program Handbook for Enrollees and Employing Offices. This is on the internet at www.opm.gov/healthcare-insurance.
Click on Healthcare, then Reference Materials and then on FEHB Handbook.
Titles of Forms Referred to in Section A:
Certified Summary of Federal Service SF 2801-1
SF 2801 Application for Immediate Retirement
SF 2801-2 Spouse's Consent to Survivor Election
SF 2802 Application for Refund of Retirement Deductions
SF 2809 Health Benefits Registration Form
SF 2810 Notice of Change in Health Benefits Enrollment
SF 176
SF 176T Life Insurance Election
SF 2817
SF 2818
Continuation of Life Insurance Coverage as an Annuitant or
Compensationer
SF 2821 Agency Certification of Insurance Status
SF 54
SF 2823
SF 3112 Documentation in Support of Disability Retirement
Designation of Beneficiary
OPM Form 1510 Certification of Agency Offer of Position and Required Documentation
DD214 Certificate of Release or Discharge from Active Duty
}
}
OPM Form 1515 Military Service Deposit Election
U.S. Office of Personnel Management
-3-
Standard Form 2801- Schedule D
CSRS/FERS Handbook for Personnel and Payroll Offices Revised June 2013
NSN 7540-00-634-4250 Previous editions are not usable.
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