Application to Make Service Credit Payment
Form Approved
Federal Employees Retirement System
OMB No. 3206-0134
To avoid a delay in processing your claim:
Federal Employees
Retirement System
1. Read the attached information carefully.
2. Typewrite or print in ink.
3. Complete Part A in full. If you are currently a Federal employee,
have your employing agency complete Part B.
Part A. To be Completed by the Applicant
1.
Name
(Last, first, middle)
2.
List
other names you have used
3.
Birthdate (mm/dd/yyyy)
4.
Address (Number and street)
5.
Department or agency in which presently or last
6.
Social Security Number
employed, including bureau, branch, or division
(City, state and ZIP Code)
7.
Location
of employment (city and state)
8. Title of position
9.
Have you previously filed any application under the Federal Employees Retirement System (FERS)
9a. Type of application
9b.Claim number(s) [if available]
or the Civil Service Retirement System (CSRS)?
Refund
Service credit payment
Yes, complete items 9a and 9b
Return of excess deductions
Retirement
No
10. List below in chronological order all periods of Federal civilian service. Be sure all your service is listed so that the Office of Personnel Management (OPM) can bill you for the correct amount.
Department or Agency
Location of Employment
Title of Position
Periods of Service
Check whether deductions were not withheld,
Show which period
(including bureau, branch or division where
(city and state)
withheld and refunded, or withheld and
of service you want to
employed)
remain to your credit
pay for first, second,
etc., by putting the
numbers 1,2,3,...
Withheld and
Withheld and
Beginning Date
Ending Date
Not Withheld
in the box below
Refunded
Not Refunded
(mm/dd/yyyy)
(mm/dd/yyyy)
11. Are deductions for the Federal Employees Retirement System now being withheld from your salary? 12. If your answer is "No," give the date of separation
Date of separation (mm/dd/yyyy)
from your last position under the Federal Employees
Retirement System
Yes
No
13. Signature of applicant
14. Telephone number (including area code) where you
15. Date (mm/dd/yyyy)
can be reached during the day
(
)
NSN 7540-01-279-6310
Standard Form 3108
3108-103
Revised November 2000
U.S. Office of Personnel Management
The February 1999 edition is usable.
CSRS/FERS Handbook for Personnel and Payroll Offices
1
2
