Form RI 38-107 RI 38-107 Verification of Who Is Getting Payments_MarkUp

Form Approved:
OMB No. 3206-0197

United States
Office of Personnel Management
1900 E Street, NW
Washington, DC 20415-0001

Date
Claim number

URGENT - Reply Required Within 30 Days to Avoid Interruption of Your Payments
For your protection, the Office of Personnel Management (OPM) is verifying your records to make sure the annuity payments and informational
correspondence we send you are going to the right person and the correct address. If we are paying you as the survivor of a deceased Federal
employee or retiree, it is your information we are verifying. The information for the deceased is already on file.
Please take the following actions promptly:
• Verify the name and address shown above for accuracy (including spelling).
• Enter the information requested in Parts A or B on page 2 of this letter.
• Sign your name in the space provided.
• Return this letter to the Office of Personnel Management in the enclosed envelope.
Thank you for your cooperation in this important matter.

Retirement Inspection Branch
202-606-0249

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 pursuant to 5 U.S. Code § 8337 (Civil Service Retirement)
and 5 U.S.C. chapter 84, subchapter V (Federal Employees' Retirement). 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: This form is used to
determine that the proper payment(s) are made to the correct person and to verify that official correspondence is sent to the correct address.
Routine Uses: The information requested on this form may be shared as a "routine use" to other Federal agencies and third-parties when it
is necessary to process your application. 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 a determination of your disability
retirement benefits, 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: Failure to provide this information would cause OPM to pay monies absent of the assurance of a correct payee.

Public Burden Statement
We estimate this form takes an average 10 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 Office of Personnel Management, Retirement Services Publications Team (3206-0197),
Washington, DC 20415-0001. The OMB Number 3206-0197 is currently valid. OPM may not collect this information and you are not required
to respond, unless this number is displayed.

Previous edition is not usable.

RI 38-107
Revised April 2018

Part A - Annuitant's Response (If the annuitant is deceased, go to Part B.)
If the annuitant cannot sign in Item 4, complete Items 1, 2, and 3 as applicable. Skip Item 4 and complete Item 5.
Item 1 - (Check one block.)
My name and correspondence address shown on the front of this notice are correct. (Complete items 2 and 4 or item 5.)
My name and/or correspondence address shown on the front of this notice are not correct. (Complete items 2, 3, and 4 or item 5.)
Item 2 - (Enter your identifying information.)

Item 3 - (Show the correct information.)

Annuity claim number

Name

Annuitant's Social Security Number Telephone number (including area code) Address

Email address

City, State, and ZIP Code

Item 4 - Signature and Certification

I hereby certify that the above information is true to the best of my knowledge and belief.
Date (mm/dd/yyyy)

Annuitant's signature (do not print)

Warning: Any intentionally false statement made above or willful misrepresentation relative thereto is a violation of the law
punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
Item 5 - If it is not possible for the annuitant to sign, provide the information requested below.
Reason the annuitant cannot sign

Printed name of person replying

Relationship to the annuitant of person replying

Address of person replying

City, State, and ZIP Code

Daytime telephone number of person replying (including area code)

Signature of person replying on behalf of the annuitant

Date (mm/dd/yyyy)

Warning: Any intentionally false statement made above or willful misrepresentation relative thereto is a violation of the law
punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
Part B - Deceased Annuitant (If the annuitant has died, give the following information.)
Place of death

Date of death (mm/dd/yyyy)

Include a copy of the death certificate.
Signature

Date signed (mm/dd/yyyy)

Your printed name and address

Telephone number (including area code)

Page 2 of RI 38-107
Revised April 2018