Fillable Sf2812 SF 2812 (U.S. Office of Personnel Management)

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Sf2812 SF 2812 (U.S. Office of Personnel Management)

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Form Approved
OMB 3206-0262
Report of Withholdings and Contributions for Health Benefits,
Life Insurance and Retirement
Interagency Report
No. 1064-OPM-AR
FROM: Address (including Department, Bureau, Location, and ZIP Code) Payroll Office Number Report Number
Month reported on Statement of Transactions Date Payroll Paid
From
PAY PERIOD
To
Telephone number (including area code)
To: OFFICE OF PERSONNEL MANAGEMENT
ATTN: FUNDS MANAGEMENT
POST OFFICE BOX 582
WASHINGTON, DC 20044-0582
I certify that the items listed herein are correct and the amount is available to
be credited to the OPM receipt account.
Signature of authorized Administrative or Certifying Officer Date
Benefit Category Withholdings Contributions
Total
LIFE INSURANCE
Basic Life
Standard - Option A
Additional - Option B
Family - Option C
Post-Retirement
Total Life Insurance
HEALTH BENEFITS
Regular
Temporary Continuation of
Coverage (TCC) - P.L. 100-654
Total Health Benefits
RETIREMENT
CSRS
All Categories
1
Salary Offset - Reemployed
Annuitants
Military and Civilian Service Credit
FERS
Regular
Military Reserve Technician
Special
2
Salary Offset - Reemployed
Annuitants
Military Deposit
FERS - RAE
Regular - RAE
Military Reserve Technician - RAE
Special - RAE
3
Salary Offset - Reemployed
Annuitants - RAE
Military Deposit - RAE
FERS - FRAE
Regular - FRAE
Military Reserve Technician - FRAE
Special - FRAE
4
Salary Offset - Reemployed
Annuitants - FRAE
Military Deposit - FRAE
Total Retirement
Grand Total
1
Employees with CPDF Retirement Codes of 1, 6, C, E, R or T.
2
Employees with CPDF Retirement Codes of L, M or O.
3
Employees with CPDF Retirement Codes of LR, MR or OR.
4
Employees with CPDF Retirement Codes of LF, MF or OF.
Public Burden Statement
We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments
regarding our time estimate or any other aspect of this form, including suggestions for reducing completing time, to the Office of Personnel Management, Funds Management, P.O. Box 582,
Washington, DC 2044. The OMB Number 3206-0262 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Office of Personnel Management Standard Form 2812
CSRS/FERS Handbook for Personnel and Payroll
This form may be locally reproduced
Revised October 2014
Offices
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Sf2812 SF 2812 (U.S. Office of Personnel Management)

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Completed 25 July 2020

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