Fillable Request For Retirement Annuity Estimate Form printable pdf download

REQUEST FOR RETIREMENT ANNUITY ESTIMATE FORM

NAME: ___________________________________________________ ESS EMPID: ____________________

Work Phone # ________________________________ Organization and Routing Symbol __________________

Projected Retirement Date(s): ________________________

__________________

Sick Leave Balance ________________ / Annual Leave Balance _________________as of ____________(date)*

CSRS

CSRS Offset

FERS

1. Which retirement system are you currently under:

Early

Optional/Voluntary

FERS MRA + 10

Disability

2. Type of Retirement you wish to apply for:

Retirement contributions to date (cumulative for this agency is reflected in ESS in the drop down menu “Review” and then

“Earnings Statement Summary”; also include all other gross pay earnings (earning from other Federal employers/agencies

other than DOE) to “This agency’s cumulative amount”). This is used to figure the non-taxable portion of the GROSS

MONTHLY ANNUITY. The non taxable portion ends when the total of all benefit payments excluded from taxes equals that

amount. NOTE: This is only an estimate, and it does not impact or reflect the actual annuity monthly payment:

CSRS $____________________________

FERS $ ___________________________

YES

N/A

Did you transfer from CSRS to FERS?

Actual/approximate date of Transfer

Sick Leave balance at time of transfer to FERS

Do you want a survivor annuity computed?

If yes, spouse’s date of birth:

If CSRS, will you elect full survivor benefits (55%):

If no, what base amount will you use?

b. If FERS, will you elect:

⁭

Full Survivor Benefits:

⁭

½ (50%):

⁭

No benefit:

Do you have any part-time Federal civilian service since 4/1/1986?

Have you ever left Federal service and withdrew your retirement deductions? If No, go to

question 5.

a. Approximately what year?

b. **Since you’ve returned to service, have you re-deposited that money?

If no, go to question 5.

c. If re-deposit is not complete, estimated amount of payments made: $

d. Will re-deposit be completed by time of retirement?

Have you ever held any temporary Federal civilian positions with the government?

a. **Have you made a deposit for that time? If no, go to question 6.

b. Is deposit complete? If yes, go to question 6.

c. Estimated amount of payments made? $

Do you have any Military service time? If no, go to question 7.

a. Was any of the service post 1956? If no, go to 6c.

b. ***Has a deposit for military service/time been made?

c. Are you receiving retired military pay?

d. Is your retirement based on combat incurred injury or disease?

e. Will you be waiving your military retirement pay?

To continue health benefits into retirement, you must have had health coverage for the 5

years immediately preceding your retirement, or from your first opportunity to enroll (this

includes Tricare for military). Do you meet this requirement?

a. If eligible, do you want to continue health benefits coverage during retirement?

(NOTE: The estimate is based on TODAY’S rate.)

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(Rev. 03/2010)

Request For Retirement Annuity Estimate Form

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