Form SF 2812A SF 2812A Report of Withholdings and Contributions for Health Bene

Report of Withholdings and Contributions for Health Benefits By Enrollment Code
Department or establishment				Payroll Office number		Report number
Bureau, division or office				Pay period from		Pay period to
Address (including ZIP Code)				Date payroll paid
				Agency telephone number
				( )
Enrollment	Total Withholdings	Number	Enrollment	Total Withholdings	Number	Enrollment	Total Withholdings	Number
Code No.	& Contributions	enrolled*	Code No.	& Contributions	enrolled*	Code No.	& Contributions	enrolled*
*Number of enrollees is required on report, for
the last payroll periods paid during the 1st through the 15th of March and September.							Standard Form 2812-A
Office of Personnel Management							Revised October 2014
CSRS/FERS Handbook for Personnel and Payroll Offices				This form may be locally reproduced