Request For Retirement Annuity Estimate Form Page 2
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2b. If yes, enrollment code: ________
Do you want to continue FEDVIP – Dental enrollment into retirement?
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a. Dental Plan Type: (Check one)
(1) Self Only
(2) Self Plus One
(3) Self Plus Family
b. Location:
State + first 3 digits of zip code: _______________ (i.e., CA955)
c. Plan Name:
Do you want to continue FEDVIP – Vision enrollment into retirement?
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a. Vision Plan Type: (Check one)
(1) Self Only
(2) Self Plus One
(3) Self Plus Family
b. Plan Name:
10
Do you have a living former spouse(s) from whom you were divorced on or after May 7,
1985, and to whom a court order gives a survivor annuity?
11
To continue life insurance coverage into retirement, you must have had coverage for the 5
years immediately preceding your retirement. If eligible, your annuity estimate will include
a deduction for Federal Employee Group Life Insurance. Do you meet this requirement?
Current FEGLI Code: _____________
Before retiring, you will be required to select a reduction level for your BASIC insurance.
Please check the reduction level you would like to be calculated for your retirement
computation.
____ 75% reduction (at age 65 basic insurance will decrease by 2% per month until it
reaches 25% of the original amount)(lease expensive option).
____ 50% reduction (at age 65, basic insurance will decrease by 1% per month until it
reaches 50% of original amount.)
_____ NO reduction (there is no change in amount of basic coverage regardless of age; most
expensive option)
OPTIONAL INSURANCE (Option B and Option C)
____ Full reduction (at age 65, basic insurance will decrease by 2% per month until it
reaches 0% of original amount.)
_____ NO reduction (there is no change in amount of basic coverage regardless of age; most
expensive option)
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The estimated Federal Taxes to be withheld:
_____ Single _____ Married
_____ Number of Exemptions Claimed
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If filing under either CSRS Offset or FERS retirement, please submit a copy of your most recent Social Security
statement to aid in the computation of your annuity supplement.
*
These can be found on your pay statements.
**
You will be given the opportunity to make these payments upon retirement if you wish to do so.
Post 1956 military deposit MUST be PAID IN FULL BEFORE retirement – you will NOT be given the opportunity
***
to make this payment after retirement.
NOTE:
THE CALCULATION THAT WILL BE DERIVED FROM THIS INFORMATION IS ONLY AN ESTIMATE. YOUR
ACTUAL ANNUITY WILL BE DETERMINED BY THE U.S. OFFICE OF PERSONNEL MANAGEMENT.
(Rev. 03/2010)
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