Standard Form 3112a - Applicant'S Statement Of Disability Page 3
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1012. List physician(s), (name(s), address(es), and dates of treatment) from whom you plan to request Physician's Statements (SF 3112C). Attach an
additional sheet if you wish to list more physicians.
Name
Address
Date of Treatments
13.
I certify that all statements made above are true to the best of my knowledge and
belief. I give my permission for the release of information about my service and
medical condition(s) (i.e., disease or injury) to authorized agency and OPM officials.
Applicant's Consent and Certification
I have read and understand all of the information provided in the instructions to
this application.
Signature (Do not print)
WARNING: Any intentionally false statement in
this application or willful misrepresentation
relative thereto is a violation of the law punishable
by a fine of not more than $10,000 or
Date (mm/dd/yyyy)
Daytime telephone number
imprisonment of not more than 5 years, or both.
(
)
(18 U.S.C. 1001)
Email address
Privacy Act Statement
Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and by the Federal
Employees Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be used to identify records properly
associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or
future benefits, and to maintain a uniquely identifiable claim file. The information may be shared and is subject to verification, via paper,
electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social security
administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination or
continuation of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above, with
law enforcement agencies when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397
(November 22, 1943) authorizes the use of the Social Security Number. Furnishing the data requested is voluntary, but failure to do so
will delay or prevent action on the retirement application.
Public Burden Statement
We estimate this form takes an average 30 minutes per response to complete, including the time for reviewing instructions, getting the
needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including
suggestions for reducing completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team
(3206-0228), Washington, D.C. 20415-3430. The OMB number, 3206-0228, is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.
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Reverse of Standard Form 3112A
3112-103
Revised May 2011
CLEAR
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