Fillable USERRA ELECTION OPTIONS Please indicate your election and (Arizona)

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USERRA ELECTION OPTIONS Please indicate your election and (Arizona)

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1 Revised May 26, 2020
USERRA ELECTION OPTIONS
Please indicate your election and acknowledgment by placing your INITIALS in the spaces provided below. If not
applicable, write N/A in brackets.
NAME: _________________________________________ WORK LOCATION: ___________________________________
(Print: Last, First, MI)
POSITION TITLE: ___________________________________________________________________________________
SUPERVISOR (CIV): _________________________________________________ ______________________________
(Print) (Phone)
1. USERRA Technician Information/Notification and Election Rights:
[______] I am a permanent, indefinite, or temporary employee. I have received the information
concerning my election rights and benefits under USERRA.
[______] I understand I am responsible for making sure the HRO has all forms: 1) USERRA Election
Options Form, 2) Military Orders, and 3) SF-52 necessary to process my AUS or separation action.
All three of the forms listed above are to be sent to the HRO as soon as possible.
2. Compensatory Time: (I wish to use the following earned comp time prior to separation or AUS)
[______] Should a Federal Technician receive orders for military service, he/she is permitted to use up any
accrued regular comp time prior to the effective date of the SF 50 for AUS purposes. You must
provide your current LES and only the displayed amount of Comp time will be used.
Hours From To
_________ ____________________ ____________________
[______] I acknowledge by signing this, any comp time that I use while AUS will cause a debt.
3. Current Work Schedule:
[______] 4/10 Work only four days a week for 10 hours a day with either Monday OR Friday off
[______] 9/8 Work eight 9 hour days & one 8 hour day in a two week period with Monday OR Friday off
[______] 5/8 Work Monday thru Friday 8 hours a day
4. I want to be: (initial one and provide effective date)
[______] Placed on Absent – Uniformed Service, effective: _______________________________
[______] Separated, effective: ______________________________________________________
NOTE: If I separate from my employment my FEHB and FEGLI will continue for 31 days after my
separation date (with the right to convert to an individual policy).
2 Revised May 26, 2020
5. Annual Leave: (I request)
[______] A lump-sum payment of all my accrued annual leave.
[______] That you retain my annual leave in my leave account until I return to civilian service.
6. Federal Employee Health Benefits (FEHB):
[______] I do not have FEHB.
[______] My military service is for 30 days or less – my coverage will continue. I need to make no further
election regarding health benefits, unless my military service is later extended past 30 days.
[______] I want to terminate my FEHB coverage effective the last day of the pay period that I have elected
to enter on active duty or placed on absent – uniformed service. NOTE: My FEHB will continue
temporarily for 31 days at no cost from the last day of the pay period.
OR
I want to continue my FEHB coverage: (initial one)
[______] I am being called to active duty in support of a contingency operation. My agency will pay my
share of the FEHB premium for up to 24 months. The 24-month period starts the date I am
placed on absent – uniformed service.
[______] My active duty is not in support of a contingency operation. I am entitled to up to 24 months of
continued FEHB coverage beginning the date my absence from my civilian position begins (i.e.,
the effective date of my entrance on active duty).
AND
I choose to pay for my FEHB by: (initial one)
[______] Making current payments on a continuing basis during my absence (with after-tax money). After
the first 12 months, I will pay 102% of the cost; the final 12 months must be paid on a current
basis. Payments are made to DFAS, NOT THE PROVIDER.
[______] Incurring a debt to be paid upon my return to civilian duty (on a pre-tax basis if I participate in
Premium Conversion) for the first 12 months. After the first 12 months, my share will be 102% of
the cost and it must be paid on a current basis.
3 Revised May 26, 2020
7. Federal Employees Group Life Insurance (FEGLI):
[______] I do not have FEGLI.
[______] I will not be on AUS for more than 12 months.
[______] I will be on AUS for more than 12 months and elect to:
[______] I elect to terminate my FEGLI coverage after 12 months.
[______] I elect to continue my FEGLI coverage for an additional 12 months. I agree to pay
the employee and government share. (See Public Law 110-181)
8. Federal Employees Dental and Vision Insurance Plan (FEDVIP):
[______] I do not have FEDVIP.
[______] I understand that if placed on AUS, I may cancel my enrollment through www.benefeds.com or
1-877-888-3337 31 days before to 60 days after my order begins. To continue FEDVIP benefits
while on active duty, you will receive a direct bill to make premiums. You are responsible for
making sure BENEFEDS has your correct address to bill you and have made arrangements to have
the bill paid on a current basis. For further information, contact BENEFEDS.
9. Flexible Spending Account (FSA):
[______] I do not have a FSA.
[______] I am aware that I must notify FSAFEDS of my entrance on absent – uniformed service status as
well as upon my return to duty by calling 1-877-372-3337.
[______] I understand that I may contact FSAFEDS to accelerate my pre-tax deductions prior to entering
non-pay status. No contributions will be deposited into my account during my absence.
[______] I understand that if I decide to separate civilian service, my FSA will terminate as of the date of
my separation. There are no extensions. Any health care expenses incurred prior to the date of
separation will still be reimbursable but those incurred after the date of separation are not
reimbursable.
10. Long Term Care (LTC) Insurance:
[______] I do not have LTC.
[______] I understand in order to continue my LTC insurance, I must keep my premium payments current
to avoid cancellation of my coverage; I may not incur a debt. I understand that it is my
responsibility to contact a LTC Representative at 1-800-582-3337 to discuss and/or change my
payment option. I also understand that if I change my payment option from payroll deduction, I
must contact a LTC Representative on return to civilian duty if I want payment by payroll
deduction reinstated.
4 Revised May 26, 2020
11. National Guard Association of the United States (NGAUS):
[______] I do not have NGAUS.
[______] I have NGAUS. (Please see NGAUS election form)
12. Thrift Savings Plan (TSP):
[______] If not contributing to Military TSP, upon my return I understand that if I make retroactive
contributions I may receive agency matching to my Civilian TSP account. To do this, I must
provide HRO
within 60 days of my return a request for retroactive contributions form.
[______] If contributing to Military TSP, upon my return I have the option to make retroactive
contributions and/or only receive agency matching on civilian TSP account. To do this, I must
provide HRO within 60 days of my return a request for retroactive contributions form.
I must provide all Military and Civilian LES’s.
[______] I have a TSP Loan(s). Attached is my form TSP-41.
13. Retirement:
[______] I understand that if I am placed on AUS, death and disability benefits continue under my
retirement system.
[______] A military service deposit (buyback) must be made for this period to be creditable for retirement
purposes.
14. Previous absences from technician position for active duty:
[______] I have never requested an absence from my technician position in the Arizona National Guard to
perform Title 10 or Title 32 active duty.
[______] I have previously been absent from my technician position to perform active duty.
15. Rideshare/Vanpool Program:
[______] Yes I am participating in the Vanpool program and will need to contact (602) 629-4800 for further
Information.
[______] No I am not participating.
16. Allotments/Garnishments:
[______] I understand that during my non-pay status I will be responsible for keeping current any
allotments/garnishments that were deducted from my pay. It is also my responsibility to notify
payees of my status.
5 Revised May 26, 2020
Statement of Understanding:
I understand the elections I have made above by signing, dating, and returning a copy of the USERRA
Election Options Form to:
OTAG-AZ, HRO
5636 E. McDowell Rd, Bldg. M5710
Phoenix, AZ 85008-3495.
__________________________________________________ _______________________
(Signature) (Date)
HOME ADDRESS: (Please include CITY, STATE, and ZIP CODE)
________________________________________________
________________________________________________
PHONE NUMBER: (Residence) __________________________________
(Cell Phone) __________________________________
E-MAIL: (Work) ______________________________________
(Personal)____________________________________
If you have any questions, please see contacts below.
USERRA BRIEFER: ___________________________________________ DATE: _________________________
HRO CONTACTS:
Stacey Mitchell, Lead HR Specialist
Phone: 602-629-4806
Email: stacey.a.mitchell6.mil@mail.mil
Cristian Acosta, Human Resources Specialist
Phone: 602-267-2057
Email: cristian.g.acosta2.mil@mail.mil
Samantha Tellez, HR Specialist
Phone: 602-629-4818
Email: samantha.l.tellez.mil@mail.mil
HRO Main Line
Phone: 602-629-4800
Desiree Sheeran, HR Specialist
Phone: 602-629-4817
Email: desiree.j.sheeran.civ@mail.mil
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USERRA ELECTION OPTIONS Please indicate your election and (Arizona)

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Completed 27 January 2021

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