Form OPM 1673 OPM 1673 Claims Coversheet

Form Approved:
OMB No. 3206-0232

Claims Coversheet
Claimant Information
1. Name of Claimant (Last, first, middle)

2. Claimant's address

3. Claimant's telephone number

4. Claimant's facismile machine number (if available)

5. Name of agency employee who denied the claim

6. Address of agency employee who denied the claim

7. Telephone number of agency employee who denied the claim

8. Facsmile number of agency employee who denied the claim
(if available)

9.Signature of Claimant

10. Date

Claim Instructions
These instructions cover claims for compensation, leave, and claims for proceeds of canceled checks for veterans' benefits payable
to deceased beneficiaries. These procedures do not apply to claims under the Fair Labor Standards Act.
(a) Content of claims. A claim shall be submitted by the claimant in writing and must be signed by the claimant or by the claimant's
designated (in writing) representative. While no specific form is required, the request should describe the basis for the claim and
state the amount sought. A claim may only be filed after it has been denied by the agency. The claim should also include:
1. The name, address, telephone number, and facsimile machine number, if available, of the claimant;
2. The name, address, telephone number, and facsimile machine number, if available, of the agency employee who denied
the claim;
3. A copy of the denial of the claim, issued by the employing agency; and,
4. Any other information, which the claimant believes OPM should consider.
(b) Agency submissions of claims. At the discretion of the agency, the agency may forward the claim to OPM on the claimant's
behalf. The claimant is responsible fo ensuring that OPM receives all the information requested in paragraph (a).
(c) Administrative report. At OPM's discretion, OPM may request the agency to provide an administrative report. This report
should include:
1. The agency's factual findings;
2. The agency's conclusions of law with relevant citations;
3. The agency's recommendation for disposition of the claim;
4. A complete copy of any regulation, instruction, memorandum, or policy relied upon by the agency in making its
determination;
5. A statement that the claimant is or is not a member of a collective bargaining unit, and if so, a statement that the claim is
or is not covered by a negotiated grievance procedure that specifically excludes the claim from coverage; and
6. Any other information that the agency believes OPM should consider.
All claims under this section should be sent to the Program Manager, Room 6484, Center for Merit System Compliance, Office of
Personnel Management, 1900 E Street NW., Washington, DC 20415. Telephone inquiries regarding these claims may be made to
(202) 606-7948.
Office of Personnel Management

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OPM 1673
April 2005

Public Burden Statement
Public burden reporting for this collection of information is estimated to take approximately 60
minutes per response, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this information
collection, including suggestions for reducing this burden, to OPM Forms Officer, U.S. Office of
Personnel Management, 1900 E Street, N.W., Washington, D.C. 20415. The OMB Number,
3206-0232, is currently valid. OPM may not collect this information and you are not required to
respond, unless this number is displayed.

OPM 1673 (Back)
April 2005