US ARMY NONAPPROPRIATED FUNDS - DISPOSITION OF RETIREMENT BENEFITS
For use of this form, see AR 215-3; the proponent agency is DCS, G1.
AUTHORITY: PRINCIPAL DISCLOSURE: DATA REQUIRED BY THE PRIVACY ACT OF 1974 Internal Revenue Service Code, Section 401(a).
ROUTINE USES: The information you provide is for the purpose of preparing a refund of contribution or to process a retirement annuity. For
terminating employees, the information is used to prepare a refund or a deferred annuity as requested. For retiring employees, the information is
used to process a monthly annuity payment thereafter. For survivors, the information is used to process survivor benefits. Disclosure of your social
security number and primary insurance amount is voluntary. Disclosure of other personal information is voluntary, however, failure to provide this
information within one year of termination of employment will result in automatic refund of contributions and denial of annuity.
SECTION I - GENERAL INFORMATION
1. EMPLOYEE'S NAME (Last, first, MI)
2. SOCIAL SECURITY NUMBER
3. DATE OF BIRTH (YYYYMMDD)
4a. COMPLETE MAILING ADDRESS
4b. E-MAIL ADDRESS
5a. AREA CODE/TELEPHONE NUMBER
5b. FAX TELEPHONE NUMBER
6. SERVICE COMPUTATION DATE (YYYYMMDD)
7. DATE OF SEPARATION AND REASON (YYYYMMDD)
8. ACCUMULATED SICK LEAVE HOURS
9. EMPLOYING NAF:
10. STANDARD NAF NUMBER
11. MARITAL STATUS (circle one)
12. NAME OF LEGAL SPOUSE (Last, First, MI)
13. SOCIAL SECURITY NUMBER OF LEGAL
14. DATE OF BIRTH OF LEGAL SPOUSE
15. DATE OF MARRIAGE (YYYYMMDD)
The date of marriage has been verified by satisfactory evidence and the benefit authorized. A certified copy of the Death Certificate and Statement
of Survivor's Social Security Entitlements are attached. Annuity Benefits resulting from the death of the employee are payable in accordance
with the Army NAF Retirement Plan.
SECTION II - RETIREMENT FUND OPTIONS
Public Law 101-508 Application for Retirement. Retained Army NAF Retirement.
16. CHECK ONE: In accordance with AR 215-3
( ) I request a refund of my contributions and accumulated interest in full satisfaction of all annuity payable.
( ) I request my contributions remain in deposit for a maximum of 5 years.
( )I request an immediate Annuity (Normal or Early Retirement).
( ) I request a Deferred Annuity payable at age 62.
( ) I request Disability Retirement. I request Disability Retirement due to work related injury.
( ) I request Survivor Benefits
SECTION III - EMPLOYEE'S OR SURVIVOR SIGNATURE
17. SIGNATURE OF EMPLOYEE/SURVIVOR
18. DATE (YYYYMMDD)
SECTION IV - VERIFICATION AND CPU MAILING ADDRESS AND SIGNATURE
19. The above information has been verified from the employee's personnel records and DA Form 3473 coded 04 is attached.
a. HRO SIGNATURE
b. DATE (YYYYMMDD)
c. HRO MAILING ADDRESS and Phone Number
d. E-MAIL ADDRESS
DO NOT USE - FOR OFFICIAL USE ONLY
20. DATE RECEIVED (YYYYMMDD)
21. DATE PROCESSED (YYYYMMDD)
22. PROCESSED BY
HROs: Send this application for retirement benefits to:
US Army NAF Employee Benefits Office, Portability Section PO Box 340309, Ft Sam Houston, TX 78234.
PL 101-508 retirements, send retirement SF 50 and verification of last sick leave balance.
DA FORM 3715, JAN 2002