RI 20-126_2015_MarkUp

Form Approved:
OMB No.: 3206-XXXX

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
February 2015

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
February 2015

Privacy Act and Public Burden Statements
Subchapter III of Chapter 83 and 84 of title 5 U.S.C. authorizes solicitation of this information. The information you furnish will be
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. The information
may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs,
with national, state, local, or other charitable or social security administrative agencies 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. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating
a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943) as amended by E.O. 13478
(November 18, 2008) authorizes use of the Social Security Number to distinguish between the applicant and people with similar
names. Failure to furnish the requested data may result in our inability to establish retirement eligibility for service credit under
the Civil Service Retirement System or the Federal Employees Retirement System.
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-XXXX), Washington, D.C. 20415-3430. The OMB Number 3206-XXXX 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
February 2015