Notice of Correction of
Individual Retirement Record
Federal Employees
Federal Employees Retirement System
Retirement System
United States Office of Personnel Management
Federal Employees Retirement System
P.O. Box 45
Boyers, PA 16017
FOLD
Please correct the FERS Retirement Record, Standard Form 3100, for the former employee named below:
Name of Employee (mm/dd/yyyy)
Agency Payroll Office No. Location
Date of Birth Social Security Number
(include ZIP Code)
Reason for Correction:
Fiscal Data
Corrected data
Amount of overstatement of total deductions
Current Year Total Cumulative Deductions
Dated
Data shown on Standard Form 3100
Correction reported on SF 2812 Number
Service History Data (Name, date of birth, appointment, separation, promotion, etc. -– Specify which)
Data shown on Standard Form 3100 Corrected Data
Standard Form 3100 forwarded to OPM on Register: Dated:
Certification
Signature Title Telephone Number Date
I certify that the corrections shown above are correct.
U.S. Office of Personnel Management NSN 7540-01-247-2026
Standard Form 3101
Revised August 2003
