Form RI 20-120 RI 20-120 Request for Change to Unreduced Annuity

OMB Approval 3206-0245

Claim number

CSA
U.S. Office of Personnel Management
Retirement Operations Center
Post Retirement
Attention: Y-Adjustment
P.O. Box 45
Boyers, PA 16017-0045

Request for Change to Unreduced Annuity
In order to change my benefit to the unreduced annuity rate, I am providing the
information below.
The reason my marriage ended is:

Spouse Died

Divorce

Annulment

The date my marriage ended is: ______________________________________________
I have enclosed: (Check one block below.)
A copy of the death certificate.
A court-certified copy of my divorce decree, including all property settlements.
A court-certified copy of my annulment.
I understand that if I have self and family health benefits coverage, I can change to selfonly at any time.
Change my coverage to self-only.
(Note: Check this block if you want to make the change. A former spouse is no longer a
family member and is not eligible for coverage under your family enrollment.)
Signature (do not print)

Date (dd/mm/yyyy)

Name (last, first, middle initial)

Email address

Telephone no. (include area code)

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 Title 5, USC, Sections 8339(j)(5)(A)
(B) and 8419(b) which allow Civil Service annuity reductions for the purpose of providing a survivor annuity to terminate after
the death of the spouse or former spouse. Purpose: OPM uses RI 20-120 to re-compute the annuity without the reduction and
to provide the pertinent information necessary for recalculation. 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 designation.
For example, 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 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. Consequences of Failure To Provide Information:
If this information is not collected, annuitants could be paid less than the law provides.

Public Burden Statement
The public reporting burden to complete this information collection is estimated at 30 minutes per response, including reviewing
instructions, searching data sources, gathering and maintaining the data needed, and completing and reviewing the collected
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Office of Personnel Management, RS Publications
Team at RSPublicationsTeam@OPM.gov. Current information regarding this collection of information – including all background
materials – can be found at https://www.reginfo.gov/public/do/PRAMain by using the search function to enter either the title of
the collection: Request for Change to Unreduced Annuity or OMB Control Number 3206-0245.
RI 20-120
Revised September 2025