Fill Out Your Ri 92 19 Form

Application for Deferred or Postponed Retirement

Federal Employees Retirement System

Form Approved: OMB number 3206-0190

Type or print clearly. If you need more space in any section, use a plain piece of paper with your name, date of birth, and Social Security Number written at the top. If you do not know an answer write “unknown.” If you are uncertain of any information you provide, answer to the best of your ability, followed by a question mark (?).

The following information should help you to answer the questions on the application which are not 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 us to locate and identify all your records.

Section C - Military Service

Item 1: Indicate whether you have performed active duty that terminated under honorable conditions in the armed services or other uniformed services of the United States, including the following:

�Army, Navy, Marine Corps, Air Force or Coast Guard of the United States.

�Cadet at the United States Military Academy, United States Air Force Academy, United States Coast Guard Academy, or Midshipman at the United States Naval Academy.

Item 4: Enter the address to which correspondence should be mailed. Do not enter the bank address where your payments will be deposited here; complete Section H of this application.

Section B - Federal Civilian Service

Item 2: Show the agency where you performed your last Federal service. Give the bureau and/or division as well as the name of the agency and include its location (city, state).

Item 3: List all Federal civilian service that you have performed. Give the bureau and/or division as well as the name of the agency, along with the agency’s location and the beginning and ending dates of the service.

�Regular Corps or Reserve Corps of the Public Health Service after June 30, 1960.

�Commissioned Officer of the National Oceanic and Atmospheric Administration after June 30, 1961 or a predecessor entity in function.

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 I of chapter 84 of title 5, and is followed by reemployment in accordance with chapter 43 of title 38 that occurs on or after August 1, 1990.

Item 2: Persons who performed active military service after December 31, 1956, must have paid a deposit to receive credit under the Federal Employees Retirement System (FERS) for their military service. You must have paid your deposit to your former employing agency. If you did not pay your deposit while you were still a Federal employee, you cannot pay it now. If you have military service performed after 1956, which is covered by a deposit you paid as an employee, check “Yes” and continue with this section. Items 2a and 2b will help us locate records of your payment.

Item 4: Indicate whether you are receiving or have applied for military retired or retainer pay (including disability retired pay and reserve retainer pay.)

If you are receiving military retired pay, your military service cannot be used for retirement purposes unless your retired pay was awarded because of a service-connected disability incurred in combat with an enemy of the United States or caused by an instrumentality of war and incurred in the line of duty during a period of war as defined by Section 1101 of title 38, or was awarded under Chapter 1223, title 10, formerly Chapter 67, title 10 and title III of Public Law 80-810 (reserve retired pay at age 60 based on 20 years of active and reserve service). Otherwise, to receive credit for your military service, you must waive your military retired pay.

To waive military retired pay for FERS retirement purposes, send a written request, specifying the effective date of the waiver and your Social Security Number, directly to the Military Finance Center from which you receive retired pay. Attach a copy of your letter to this application. You should mail this letter at least 60 days before your annuity will begin. Your letter might say, “I, (full name, military serial number, and Social Security Number), hereby waive my military retired pay for FERS retirement purposes, effective close of business (specify the day before annuity begins).” If you wish, add “I authorize the Office of Personnel Management to withhold from my retirement annuity any amount of military pay granted beyond the effective date of this waiver due to any delay in receiving or processing this election.” This authorization may hasten the processing of your waiver and your retirement application.

If you have already waived military retired pay in order to receive credit for your active military service for FERS retirement purposes, attach a copy of your request for waiver and of any reply you have received.

Obtain counseling from the military before waiving military retired pay for FERS retirement if you receive or may receive Combat Related Special Compensation (CRSC) or concurrent receipt of military retired pay and veterans compensation.

Reminder: Even if you have waived military retired pay or qualify for one of the exceptions to waiver, you must have paid a military deposit for your military service performed after 1956 to receive credit for the service in your FERS annuity, and the military deposit must have been paid to your employing agency before you separated from FERS covered Federal employment.

Section D - Other Claim Information

Item 3: If you have applied for or have ever received workers’ compensation from the Office of Workers’ Compensation Programs (OWCP), U.S. Department of Labor, because of a job-related illness or injury, check the “Yes” box and furnish your claim number(s), type(s) of benefits, and date(s) of benefits in 3a, 3b and 3c.

The information requested regarding benefits from the OWCP is needed because the law prohibits payment of both FERS retirement annuity and compensation for total or partial disability under the Federal Employees’ Compensation Act at the same time. In some cases, credit for service, particularly for periods of leave without pay, may also be affected.

Section E - Marital Information

Item 2: Indicate whether you have a living former spouse to whom

a court order awards a survivor annuity or a portion of your retirement benefits based on your Federal employment. If you answer “Yes,” you must submit a copy of the divorce decree and any attachments or amendments.

Section F - Annuity Election

Read the information about survivor benefits and their associated cost found in the pamphlet “Applying for Deferred or Postponed Retirement Under the Federal Employees Retirement System” (RI 92-19A) before completing Section F.

To be eligible for a 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. The marriage duration requirement does not apply if your death is accidental.

Survivor elections terminate upon the death of the person elected. An election of a survivor annuity for a current spouse in box 1 or 2 also terminates upon a divorce from that spouse. An election of a survivor annuity for a former spouse in box 5 also terminates if that former spouse remarries before age 55, unless the annuitant and the former spouse were married for 30 years or more. You must notify us when one of those events terminating a survivor election occurs. Also notify us if a former spouse who is entitled to a survivor annuity under a court order accept­ able for processing becomes ineligible for the former spouse annuity because of a reason specified in the court order or because of a remarriage prior to age 55.

Please note that, in accordance with the law, both a survivor annuity election made at retirement and survivor annuity election made before a divorce, terminate upon death or divorce and the annuitant must make a new election (reelection) within 2 years after the terminating event to provide a survivor annuity for a spouse acquired after retirement or for a former spouse. Continuing a survivor reduction, by itself, is not effective to reelect a survivor annuity for a spouse married after retirement or for a former spouse.

Item 4: If you initial box 4, a person selected by you at retirement who has an insurable interest in you, will receive a survivor annuity upon your death. Enter the requested information about that person. Insurable interest exists if the person named (such as a close relative) may reasonably expect to derive financial benefit from your continued life.

You must provide documentation that you are in good health in order to choose this type of annuity. You will be notified of the additional evidence required.

If you choose this type of 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 following table. The survivor’s rate will be 55% of your reduced annuity.

Reverse of Instruction Page 1, RI 92-19

Revised May 2012

You may elect this insurable interest survivor annuity in addition to a regular survivor annuity for a current or former spouse. However, if you elect an insurable interest annuity for your current spouse, you must both jointly waive the current spouse annuity. Generally, an insurable interest annuity cannot be cancelled. However, if you elect an insurable interest annuity for your current spouse because a former spouse is entitled to the regular survivor annuity (under a court order acceptable for processing or based on your election of that survivor benefit for the former spouse), you can convert the insurable interest election for your current spouse to a current spouse annuity within two (2) years of the former spouse losing entitlement to the regular survivor annuity.

Item 5: If you initial box 5, your former spouse(s) will receive a survivor annuity upon your death. The maximum survivor annuity payable to your former spouse(s) is 50% of your unreduced annuity. Your annuity will be reduced 5% or 10% according to the total benefit you want to provide.

If you are married and initial box 5, you must complete and attach Schedule A - Spouse’s Consent to Survivor Election, to your application. The law requires consent of the spouse if a married person elects a full or partial survivor annuity for a former spouse. You may not elect a combined benefit for your current and former spouse(s) which exceeds 50% of your benefit.

Section G - Information About Children

Complete Section G by providing the names and dates of birth of your unmarried dependent children under the age of 22. Also list any child over the age of 22 who is incapable of self-support because of mental or physical disability incurred before the age of 18. Check the box headed “disabled” by the name of each child to whom this applies. Information about your children in your annuity claim file may help to expedite the processing of claims for survivor benefits when you die.

Section H - Payment Instructions

Complete in all cases. The U. S. Department of the Treasury pays all Federal benefit payments electronically. Most Federal payments are paid by Direct Deposit into a savings or checking account at a financial institution. If you do not have a bank account, or prefer not to have your annuity payments deposited directly to your bank account, you can choose a Direct Express debit card. If you choose this option, your annuity payment will be automatically deposited to the Direct Express card on the payment date. To obtain a debit card, go to www.godirect.org or call 1-800-333-1795. 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 Treasury at 1-800-333-1795.

You cannot receive your annuity payments by direct deposit or the Direct Express debit card program if your permanent payment address is outside the United States in a country where these programs are not available.

Item 2: You may obtain your Financial Institution Routing Number by calling your bank, credit union, or savings institution. This number is very important. We cannot pay by direct deposit without it. We suggest you call your financial institution to verify this number.

If you prefer, you may attach a cancelled personal check that shows the information requested 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 correct information for direct deposit. (Some financial institutions, especially credit unions, use different routing numbers on checks.) We can then use this information to start paying you by direct deposit.

Section I - Applicant’s Certification

Be sure to sign (do not print) and date your application after reviewing the warning.

Schedules (Attachments)

There are three schedules attached to this application for deferred or postponed retirement. Some of these schedules may apply to you and some may not. Read the following to determine which schedules you should complete. Instructions for completing and information about each follows.

Schedule A - Spouse’s Consent to Survivor Election

Complete this schedule if you are married and, in Section F, you do not elect box 1, a maximum survivor annuity for your spouse. For any other election you must obtain your spouse’s consent. (See the pamphlet entitled “Applying for A Deferred or Postponed Retirement Benefit Under the Federal Employees Retirement System” (RI 92-19A) for information about asking the Office of Personnel Management (OPM) to waive the spousal consent requirement in special circumstances.)

Instruction Page 2, RI 92-19

Revised May 2012

Part 1: You must complete this section. Include your name, date of birth and social security number as shown on your application. Check the box(es) that corresponds to the selection(s) you made in Section F on your application. Check all boxes that apply.

Part 2: Your spouse completes this section, in the presence of a notary public.

Part 3: A notary public or other person authorized to administer oaths (e.g., a justice of the peace) must complete this section, after witnessing your spouse’s signature.

Schedules B & C - For Applicants Who Have At Least 10 Years of Creditable Service

If you have at least 10 years of creditable service (5 of which must be civilian) which will be used to compute your benefit, then you must complete one of these two schedules. Do not complete either of these schedules if you have less than 10 years of service.

Complete Schedule B if you had attained the Minimum Retirement Age (MRA) when you left Federal service and had at least 10 years of creditable service. You are eligible to choose when you want your benefit to begin and may be eligible to reenroll in the health benefits, life insurance and Federal Dental and Vision programs and carry them into retirement.

Complete Schedule C if you had not yet attained the MRA when you left Federal service, but you did have at least 10 years of creditable service. You are eligible to choose when you want your benefit to begin.

The MRA is based on the year of your birth and determines the earliest date you became eligible to have your retirement annuity begin. The Minimum Retirement Age Schedule is:

Schedule B

Part 2: You may choose to have your annuity begin on:

1.the first day of the month following your separation from Federal service; or

2.the first day of any month which is at least 31 days after the Office of Personnel Management (OPM) receives your application for retirement (but before your 62nd birthday).

Your annuity will be reduced by 5/12 of 1% for each full month (5% per year) that the date your annuity begins precedes your 62nd birthday. You can avoid the age reduction entirely if you choose the first day of the month that you reach age 62 as your annuity commencing date. The age reduction does not apply if your annuity commences the first day of the month after your 60th birthday and you have at least 20 years of service.

Parts 3 People who leave Federal service after reaching the MRA with at least

and 4: 10 years of creditable Federal service are eligible to reenroll in the Federal Employees Health Benefits Program and the Federal Employees’ Group Life Insurance Program if they had participated in the program for the 5 years of service immediately before their separation date or continually from their earliest opportunity. If you were enrolled in either of these programs when you left Federal employment and you had already attained your MRA and had 10 years of creditable service, complete these sections. If you want information about reenrolling in either program, indicate so in item 1b.

Part 5: People who leave Federal service after reaching the MRA with at least 10 years of creditable Federal service are eligible to reenroll in the Federal Dental and Vision Insurance Program (FEDVIP). If you were enrolled in FEDVIP when you left Federal employment and you had already attained your MRA and had 10 years of creditable service, complete this section. If you want information about reenrolling, indicate so in item 1b.

Part 6: If you are enrolled in the Federal Long Term Care Insurance Program (FLTCIP), your coverage will continue. No action is required by you. However, you may choose to have your premium payments deducted from your annuity. To elect annuity deduction of premiums, please call Long Term Care Partners, at 1-800-582-3337 (TTY: 1-800-843-3557).

If you are not currently enrolled in the FLTCIP, you, your spouse, and your adult children may apply for FLTCIP coverage provided you are eligible for a deferred or postponed annuity. You may request an application by calling Long Term Care Partners, at 1-800-582-3337 (TTY: 1-800-843-3557), or by visiting www.ltcfeds.com.

Schedule C

Part 2: You may choose to have your annuity begin on:

1.the first day of the month following the month in which you reach your MRA; or

2.the first day of any month which is at least 31 days after OPM receives your application for retirement if you have reached your MRA (but before your 62nd birthday).

Application for Deferred or Postponed Retirement

Form Approved: OMB No. 3206-0190

Federal Employees Retirement System

Federal Employees Retirement System

1.Date on which you separated from Federal service (mm/dd/yyyy)

2.What agency did you separate from? (Give agency, group or office)

3.List below all Federal service you have performed.

Department or Agency, including Bureau or Division

Location (City and state)

Dates of Service

From (mm/dd/yyyy) To (mm/dd/yyyy)

Yes, go to item 2.

No, go to Section D.

Not applicable, go to item 3.

Yes, go to item 2a.

No, go to item 3.

2a. When did you pay your deposit for post-56 military service? (mm/dd/yyyy)

2b. To which agency did you make the payment? (Give agency, bureau or division and

location)

Yes (Complete items 1a and 1b)

No

1a. Type of application

Retirement

Refund

Deposit/redeposit

Refund of excess deductions

1b. Claim number(s)

Initials

If you are married at retirement you will automatically receive this type of annuity unless your spouse consents to your election not to provide maximum survivor benefits. If you receive this annuity, your annuity will be reduced by 10%. The survivor's annuity upon your death will be 50% of your unreduced annuity.

Initials

If you choose this option, your annuity will be reduced by 5%. Upon your death, your spouse's annuity will be 25% of your unreduced annuity. You must have your spouse's consent to choose this option. Attach Schedule A showing your spouse's consent.

Initials

No current spouse survivor annuity will be paid to your spouse after your death if he or she consents to this election. If you are married at retirement, you cannot choose this type of annuity without your spouse's consent. You should initial this box if you are electing an insurable interest benefit (Box 4) for your current spouse. Attach Schedule A showing your spouse's consent. If you are eligible to continue your health benefits coverage into retirement, your spouse's health benefits coverage will terminate upon your death. In addition, your spouse will not be eligible to enroll in the Federal Long Term Care Insurance program, if he/she is not enrolled at the time of your death.

Initials

You must be healthy and willing to provide medical evidence if you choose this type of annuity.

Name of person with insurable interest

Relationship to you

Date of birth (mm/dd/yyyy)

Social Security Number

Initials

You must attach: 1. Certified copies of divorce decrees for all former spouses for whom you elect to provide survivor annuity.

2.If you are married, attach a completed Schedule A (Spouse's Consent to Survivor Election). You cannot choose this option and provide a maximum survivor annuity for your spouse (Box 1).

Your election to provide a survivor annuity for a former spouse terminates upon the death of that spouse or the remarriage of your former spouse before age 55 (unless your marriage to the former spouse lasted for 30 years or longer).

Total (Must equal either 25% or 50%)

0%

Dependent Child's Name

(First, middle, last)

Date of Birth

(mm/dd/yyyy)

Disabled



Dependent Child's Name

(First, middle, last)

Date of Birth

(mm/dd/yyyy)

Disabled



2.Please provide information about your financial institution below.

Section I - Applicant's Certification

2d. Telephone number of your financial institution

(including area code)

Warning

Any intentionally false statement in this application or willfully misleading statement or response you provide in this application 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 that no evidence necessary to the settlement of this claim is withheld. I have read and understand all the information provided in the instructions to this application.

Name (Last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

Name (Type or print)

Signature (Do not print)

Date (mm/dd/yyyy)

Social Security Number

Yes, complete items 1a-1c.

No, go to Part 4.

1a. What coverage(s) did you have when you separated?

1b. Do you want information on starting your coverage(s) again?

1c. Did you convert your coverage(s) to a private plan?

1d. Do you have a copy of your SF 2821 terminating your coverage(s)?

Yes

No

1. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?

Yes. Your coverage will continue. If you want your premium payments deducted from your annuity, call the FLTCIP administrator, Long Term Care Partners, at 1-800-582-3337.

No. If you are not currently enrolled in the Federal Long Term Care Insurance Program, you, your spouse, and your adult children may apply for coverage provided you are eligible for a deferred or postponed annuity. You may request an application by contacting Long Term Care Partners, at 1-800-582-3337.

Part 7 - Applicant's Signature

Signature

Date (mm/dd/yyyy)