RI 20-64A_2011_08_MarkUp

Form Approved:
OMB number: 3206-0235

U.S. Office of Personnel Management
Civil Service Retirement System
Boyers, PA 16017

Former Spouse Survivor Annuity Election
Civil Service Claim Number
CSA

Part 1: To Be Completed by Retiree
1. Your name (last, first, middle)

2. Are you now married? (If yes, complete item 2a
and see note below.)
No
Yes

2a. Name of current spouse (last, first, middle)

3. Former spouse's name (last, first, middle)

4. Former spouse's Social Security Number

5. Former spouse's mailing address

6. Election: I elect a reduced annuity to provide a survivor annuity for my former spouse named in block 3 above. I have read and
understand the information in the accompanying letter and pamphlet.
(Choose one of the following as a base for computing the former spouse survivor annuity.)
Use the maximum amount now available.

Use the same amount for which my annuity is now reduced.

Use the amount that will currently provide a survivor annuity rate of $__________ per month. (Specify a whole dollar amount, not
more than the survivor rate shown in item 4 of Part B in the letter.)
Important: This Election Is Irrevocable After You Submit It To OPM.
7. Your signature (do not print)

8. Date (mm/dd/yyyy)

9. Daytime telephone number (including area code)

Note: Married retirees must have their current spouse's written consent to this election. If you are married, have your current spouse
complete Part 2. Part 2 must be completed in the presence of a Notary Public or other person authorized to administer oaths. The certifier
must complete Part 3. The current spouse consent requirement may be waived under certain conditions. See Part II of the enclosed
pamphlet for more information. If you want to request a waiver, attach an explanation to this application.
Part 2: To Be Completed by Current Spouse if Retiree Is Married
I freely consent to the survivor annuity election described above. I understand that my consent is final and cannot be revoked.
1. Name (type or print)

2. Signature (do not print)

Part 3: To Be Completed by A Notary Public Or Other Person Authorized to Administer Oaths
I certify that the person named in Part 2 presented identification (or was known to me), signed or marked this form, and acknowledged that
the consent was freely given in my presence on the ____________ day of ____________________________________________________
(month)
_______________ at ______________________________________________________________________________________________
(year)
1. Signature (do not print)

2. Name and title of certifier (type or print)

Seal
3. Expiration date of commission if Notary Public

Continues on the Reverse
Previous editions are not usable.

RI 20-64A
Revised August 2011

Part 4: If You Decide Not To Provide A Survivor Benefit
Please indicate your decision below, provide your signature and date, and return this election form to the address shown in Part C of the letter.
I have decided not to provide a survivor benefit for (enter name of person):
Signature

Date (mm/dd/yyyy)

Privacy Act Statement
Title 5, U.S. Code, authorizes solicitation of this information. The data you furnish will be used to determine your eligibility to receive a reduced annuity
and to give a survivor annuity to your former spouse. This 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 to determine and issue
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. Provision of this information is voluntary; however, failure to supply all of the requested information may result in an inability to
reduce your annuity for your former spouse. We also request that you provide your former spouse's Social Security Number so that it may be used as an
individual identifier in the Civil Service Retirement System. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security number.

Public Burden Statement
We estimate the election letter takes an average 45 minutes per response 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 U.S. Office of Personnel Management, Retirement Services Publications Team (3206-0235), Washington, DC 20415-3430. The OMB Number,
3206-0235, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

RI 20-64A
Revised August 2011