REQUEST FOR RETIREMENT CALCULATION

Please complete the information below and return by fax to 301-504-1540 or mail to:

USDA, ARS, HRD, REE Services Branch

Retirement & Benefits Staff

5601 Sunnyside Avenue

Beltsville, Maryland 20705-5107
If you have any questions concerning this form, please call 301-504-1526 or contact your servicing Benefits Specialist found at: www.afm.ars.usda.gov/divisions/hrd/hrdhomepage/retirement/ASSIGN.htm

Thank you.
NAME:
SSN:
WORK/HOME (WHERE YOU CAN BE REACHED DURING THE DAY)
PHONE NUMBER:
DATE OF RETIREMENT:
TYPE OF RETIREMENT:
1. OPTIONAL	2. DISABILITY	3. DEFERRED	4. DISCONTINUED SERVICE
SICK LEAVE BALANCE AS OF DATE OF RETIREMENT
ARE YOU MARRIED:	YES	NO
HAVE YOU EVER TAKEN A REFUND OF YOUR RETIREMENT CONTRIBUTIONS:
YES	NO
IF YES, WHAT YEAR
IF YES, HAVE YOU PAID BACK THE REFUND TO THE OFFICE OF PERSONNEL MANAGEMENT:
YES	NO
HAVE YOU PAID A DEPOSIT FOR ANY NON-DEPOSIT SERVICE (THIS IS SERVICE WHEN YOU WERE NOT ELIGIBLE TO PAY INTO THE RETIREMENT SYSTEM UNDER APPOINTMENTS SUCH AS NOT TO EXCEED (TEMPORARY) OR TERM:
YES	NO
DO YOU HAVE ANY MILITARY SERVICE:	YES	NO
IF YES, HAVE YOU PAID THE POST-56 DEPOSIT:	YES	NO
IF YES, ARE YOU RETIRED MILITARY:	YES	NO
IF YES, DO YOU PLAN ON WAIVING YOUR MILITARY RETIRED PAY IN ORDER TO RECEIVE CREDIT UNDER THE CIVILIAN FEDERAL SERVICE:
YES	NO	NOT SURE
If you have a copy of your social security earnings statement and are covered under CSRS/Offset or FERS, please provide a copy with this request.
PLEASE PROVIDE A "HOME" MAILING ADDRESS:
Would you like the forms necessary to file for retirement mailed with this calculation?	YES	NO