Voluntary Contributions Election
Before you make your election, please read all of the information about refunds of voluntary contributions in the Voluntary
Contributions Notice, RI 38-125, and the Special Tax Notice Regarding Rollovers, RI 37-22. For more information about voluntary
contributions or this election, call 1-888-828-9451.
Please print clearly when you provide the following information:
Your name (last, first, middle)
Date of birth (mm/dd/yyyy)
Your address
Daytime telephone number
(including area code)
Your Voluntary Contributions Account Number
Your Social Security Number
VC
Date of Retirement or Separation (if applicable) _________________________
Give us your election by selecting item 1, 2, or 3.
To receive a refund by selecting item 3, please send this form to the Office of Personnel Management, Retirement Operations Center, PO
Box 45, Boyers, PA 16017-0045, Attn: Refund Section. If you are retiring, send this form at least 60 days before your separation date. If
you are making voluntary contribution payments via Pre-Authorized Debit (PAD), you must contact OPM, P.O. Box 979062, St. Louis, MO
63197-9000, in writing or call 888-828-9451 to have the debits discontinued. To purchase additional annuity by selecting item 1, return this
form to your personnel office with your application for retirement.
1. Additional Annuity
I want to use my voluntary contributions (VC), plus interest, to purchase additional annuity.
Please check (
) one of the following options.
I want to provide a VC survivor annuity for the person named
I do not want to provide a VC survivor annuity.
below.
His/Her date of birth (mm/dd/yyyy)
Name of person (last, first, middle)
His/Her address
His/Her Social Security Number
His/Her relationship to you, if any
Warning:
Any intentionally false or willfully misleading response you provide in this election is a violation of the law and
punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years or both. (18 USC 1001)
Signature
Date (mm/dd/yyyy)
2. Send Me Additional Information After I Retire
I do not want to make an election at this time. I want the Office of Personnel Management (OPM) to send me information that is
specific to my case. I understand this information will be sent after OPM receives my application for retirement.
Signature
Date (mm/dd/yyyy)
(continued on Page 2)
RI 38-124
Revised July 2010
This form may be locally reproduced
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