Please provide the following information:

Last Name:  

First Name: 

Middle Name: 

Last Four (4) Digits of Your Social Security Number: 

Retirement System:  Civil Service Retirement System (CSRS) Civil Service Retirement System (CSRS) Offset Federal Employees Retirement System (FERS) Civil Service Retirement System (CSRS) -Special (Firefighter) Federal Employees Retirement System (FERS) - Special (Firefighter) Other Select One

Home Street Address: 

City:   

State/Country:    

Zip Code/Postal Code: 

Activity: Select One CSO-C CSO-N DCMA DSCC DSCR DSCP DRMS DLIS DDC DNSC DAPS HQ DESC CPMS DHRA DLA-Europe DLA-Pacific

Activity City: 

Activity State: 

Telephone Numbers with Area Code:
Work:     Home:      Fax: 

How would you like your estimate returned:   FAX         Mail

E-Mail Address (If available): 

Position Title:       

Pay Plan/Series/Grade:   Select One GS GM WG WD WL WS     Select One 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Projected Retirement Date:  ( MM DD YYYY  ex: 02 10 2002)

Hours of sick leave you expect to have at retirement (CSRS and CSRS-Offset Only):
 

Type of retirement benefit for which applying?  Voluntary-Optional Special Group (LEO/FF) Deferred Voluntary Early Disability Discontinued Service Minimum Retirement Age plus 10 years of Service Select One

If your activity is currently offering VSIP do you want a VSIP computation?  Yes     No

INSURANCE INFORMATION:

Will you elect to take Health Insurance into retirement?  Yes No Select One  

Will you elect to take Life Insurance into retirement?   Yes No Select One  

If you elect to continue FEGLI coverage into retirement, please select from the following options:   
Basic:        Yes    No             Reduction  No Reduction 50% Reduction 75% Reduction Select One

Option A:   Yes    No

Option B:  Yes    No
Number of multiples you want to continue?  Select One 1 2 3 4 5 and Full Reduction No Reduction Select One

Option C:   Yes    No
Number of multiples you want to continue?  Select One 1 2 3 4 5 and Full Reduction No Reduction Select One

MARITAL STATUS and SURVIVOR ELECTIONS

Are you married?:  Yes No Select One

If yes, do you want to provide a survivor annuity for your current spouse?  Yes No Select One

Do you have a court order awarding a survivor annuity to a former spouse, from whom you were
divorced on or after May 7, 1985?  Yes No Select One

Do you want to provide a survivor annuity for a former spouse?  Yes      No

Do you want to elect an Alternative form of Annuity (AFA)?   Yes      No

Do you want Federal Tax Withholding deducted?

    Filing status: Select One Single Married
    Number of  exemptions: 

MILITARY SERVICE:

Were you in the military?  Yes No Select One

Did you serve on active duty after 1956?  Yes No Select One

If yes, have you made the deposit for this service?  Yes No Select One

If yes, do you have a copy of the receipt?  Yes      No

If no, do you plan to make the deposit?  Yes No Select One

If you are a military retiree, do you plan to waive your military retired pay in order to combine
this service with your civilian service?  Yes No Select One

Is there a copy of your Military Discharge (DD 214) in your official personnel folder (OPF)?  Yes No Select One

OTHER TYPES OF SERVICE AND BASIC PAY INFORMATION

Have you performed part-time service after April 6, 1986?  Yes No Select One

Have you worked on an intermittent appointment?  Yes No Select One

Have you worked under a temporary appointment?  Yes No Select One  

If yes, have you paid the deposit for that service?  Yes No Select One

Have you worked as a NAF (nonappropriated fund) employee?  Yes No Select One

Have you had more than 6 months of Leave Without Pay (LWOP) in a calendar year during any part of the past three years?  Yes No Select One

Have you worked continuously on second or third shift during the last three years?  Yes No Select One  
If yes, what shift:  Second Third Select One

Have you ever resigned from a federal job, applied for and received a refund of your
retirement contributions?  Yes No Select One

If yes, please provide the amount you withdrew and the date you received the money:

Amount:   

Date:  (mm dd yyyy - ex: 02 10 2002)

Have you ever received severance pay?  Yes No Select One  

If Yes, please provide the starting date and ending date you received the money.
starting date:        ending date:    (mm dd yyyy - ex: 02 10 2002)

Have you ever received Voluntary Separation Incentive Pay?  Yes      No

If Yes, how much? 

when?  (mm dd yyyy - ex: 02 10 2002)

Additional Comments: