RI 20-126_2019_05_MarkUp

Form Approved:
OMB No.: 3206-0268

Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84
Service That Can Be Used To Establish Retirement Eligibility Under The Civil Service Retirement System or
The Federal Employees Retirement System
This certification is to be completed by the appropriate personnel official of the agency or independent entity as defined in Section 1905 of Public Law 111-84
Section 1: Employee Information
Employee Name (Last, First, Middle Initial)

Date of Birth (mm/dd/yyyy)

Social Security Number

Section 2: Qualifying District of Columbia Service as defined in Section 1905(a)(2) or 1905(b) of Public Law 111-84
Agency or Independent Entity certifying the service below
Agency or Independent Entity where service was
performed or in the case of (b)(4),
agency or Independent entity that
appointed the employee

Start Date

End Date

Intermittent
Time Worked
(hours or days)

LWOP
(hours, days,
or dates)

Total Amount of
Creditable Service
Yrs

Mos

Days

Type of Qualifying
1905(b) service; i.e.,
(b)(1), (b)(2), (b)(3), or
(b)(4) [see instructions
on back]

Detention
Officer Service
(see back)
Yes

No

►

Total Qualifying Service
Comments:

Section 3: Agency Certification
I certify that the information shown above accurately reflects verified information in official records.
Signature of Authorized Agency or Independent Entity Official

Title

For Local Reproduction

Telephone Number (including area code)

Printed Name of Authorized Agency or Independent Entity Official

Email Address

Date (mm/dd/yyyy)

RI 20-126
Revised May 2019
Previous edition is not usable.

Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84
Service That Can be Used To Establish Retirement Eligibility Under the Civil Service Retirement System or

The Federal Employees Retirement System
Instructions
This certification form must be completed by an agency or independent entity official in which the employee claims qualifying service as
defined in section 1905 of the National Defense Authorization Act (NDAA), Public Law 111-84, approved on October 28, 2009. (This law
applies to employees covered under the Civil Service Retirement System (CSRS) or the Federal Employees Retirement System (FERS) on or
after October 28, 2009). While certain DC government service is allowed to meet retirement eligibility, note the service cannot be used in the
computation of the retirement benefit. The agency official is certifying that the employee performed service with the District of Columbia (DC)
that is qualifying under section 1905 of PL 111-84 for determining retirement eligibility under CSRS or FERS, or, in the case of (b)(4), the
agency or independent entity that appointed the employee. The certifying official is the lead Agency Benefits Officer listed at one of the
following agencies or independent entities as follows: Department of Justice, District of Columbia Courts, Court Services and Offender
Supervision Agency, Pretrial Services Agency, and the Public Defender Service for the District of Columbia. The lead benefits officers are listed
on the OPM website at https://apps.opm.gov/abo.

•

Make separate entries for each unique period of service described as qualifying service and for each period of qualifying service
performed as a Detention Officer as defined in Section 626.04(2) DC Code. Also make separate entries for each:
-

period of service during which the employee performed service under an intermittent work schedule, providing the amount of time
worked during the period of intermittent service, and

-

year during which the employee worked full-time or part-time and had leave without pay (LWOP), providing the amount of leave
without pay.

•

Take into account adjustments made because of intermittent time and/or excess LWOP, enter the amount of creditable service (years,
months, days), and then provide the total amount of creditable service at the bottom of the certification.

•

Provide the section of 1905(b) under which the service was performed. For purposes of section 1905, “qualifying DC service” means any
of the service described below in (b)(1), (b)(2), (b)(3), and (b)(4) and for which the individual did not ever receive credit under the
provisions of subchapter III of chapter 83 and 84 of title 5, U.S.C. (for reasons other than being excluded from retirement coverage
under section 8331(1)(iv)):
(b)(1)

Service performed by an individual as a nonjudicial employee of the DC Courts which was performed prior to the effective date
of the amendments made by section 11246(b) of the Balanced Budget Act of 1997. (The certifying official is the lead Agency
Benefits Officer at the DC Courts).

(b)(2)

Service performed by an individual as an employee of an entity of the DC government whose functions were transferred to the
Pretrial Services, Parole, Adult Supervision, and Offender Supervision Trustee under section 11232 of the Balanced
Budget Act of 1997 which was performed prior to the effective date of the individual’s coverage as an employee of the Federal
government under section 11232(f) of such Act. (The certifying official is the lead Agency Benefits Officer at the Court Services
and Offender Supervision Agency (CSOSA) or if applicable, the Pretrial Services Agency within CSOSA).

(b)(3)

Service performed by an individual as an employee of the Public Defender Service for the District of Columbia which was
performed prior to the effective date of the amendments made by section 7(e) of the DC Courts and Justice Technical
Corrections Act of 1998. (The Public Defender Service for the DC is an independent federally funded organization, not subject
to title 5 of the U.S.C.; however, its employees are covered under CSRS and FERS). (The certifying official is the lead Agency
Benefits Officer at the Public Defender Service).

(b)(4)

Service performed by an individual who was an employee of the DC Department of Corrections who was separated from service
as a result of the closing of the Lorton Correctional Complex and who was appointed to a position with one of the following
entities. (The certifying official is the lead Agency Benefits Officer at the appropriate agency/independent entity listed below
and certifies in conjunction with the list of employees who separated as a result of the closing of the Lorton Correctional
Complex. This list of former Lorton Correctional complex employees was prepared by the DC Government and submitted to the
lead Agency Benefits Officers via OPM in May 2010).

•
•
•
•
•
•

Bureau of Prisons (Department of Justice)
US Parole Commission (Department of Justice)
DC Courts (District of Columbia Court of Appeals and Superior Court of the District of Columbia)
Court Services and Offender Supervision Agency (CSOSA)
Pretrial Services Agency (An independent entity within CSOSA)
Public Defender Service for the District of Columbia

• If the employee was a Detention Officer as defined in Section 1-626.04(2) DC Code during the qualifying service, check “yes” under the
“Detention Officer” column. Check “no” in that column if the employee was not a Detention Officer during the period entered.

• File the completed certification form on the permanent side of the employee’s Official Personnel Folder (OPF) or electronic official
personnel folder (eOPF) until the employee separates for retirement or dies.

• Forward the original certification form, and any other such certification forms that may be already on file in the OPF or eOPF, to the
Office of Personnel Management when the employee retires or dies.

Page 2 of RI 20-126
Revised May 2019

Privacy Act Statement
Pursuant to 5 U.S.C.§ 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form.
Authority: OPM is authorized to collect the information requested on this form by Subchapter III of Chapters 83 and 84 of title 5 U.S.C. OPM
is authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478
(November 18, 2008). Purpose: The information collected on this form is used to identify records properly associated with your application for
Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a uniquely
identifiable claim file. Routine Uses: The information requested on this form may be shared externally as a "routine use" to other Federal
agencies and third-parties when it is necessary to process your application for benefits. For example, OPM may share your information with
other Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain information necessary
for determination or continuation of benefits under this program, or to report income for tax purposes. OPM may also share your information
with law enforcement agencies if it becomes aware of a violation or potential violation of civil or criminal law. A complete list of the routine
uses can be found in the OPM/CENTRAL 1 Civil Service Retirement and Insurance Records system of records notice, available at
www.opm.gov/privacy. Consequences of Failure to Provide Information: Providing this information to OPM is voluntary. However, if you
fail to provide this information, may result in our inability to establish retirement eligibility for service credit under the Civil Service Retirement
System or the Federal Employees Retirement System.

Public Burden Statement
We estimate that this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data,
and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing
completion time, to the Office of Personnel Management, Retirement Services Publications Team (3206-0268), Washington, D.C. 20415-0001.
The OMB Number 3206-0268 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number
is displayed.

Page 3 of RI 20-126
Revised May 2019