ELECTION OF RETIREMENT COVERAGE
FOR REEMPLOYED FEDERAL EMPLOYEES RETIREMENT SYSTEM (FERS)
DISCONTINUED SERVICE RETIREMENT (DSR) ANNUITANTS
(As authorized by section 9902(h) of title 5, United States Code)
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 5 U.S.C. Chapters 83, 84, and 99; 5 U.S.C. 9902(h)(2), Provisions Relating
to Reemployment; and DoD Instruction 5400.25, DoD Civilian Personnel Management System: Volume 300, Employment of Federal
Civilian Annuitants in the Department of Defense.
PRINCIPAL PURPOSE(S): To determine and allow present or future benefits and to establish a system of records to provide
Human Resource information and system support for the DoD civilian workforce worldwide. Specifically, to document the retirement
coverage selected by reemployed FERS discontinued service retirement annuitants.
ROUTINE USE(S): The DoD "Blanket Routine Uses" apply.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in a missed opportunity to elect retirement
(Reemployed Annuitant's Full Name)
(Date of Birth - YYYYMMDD)
have read the "Notice to Reemployed Federal Employees Retirement System (FERS) Discontinued Service Retirement (DSR)
Annuitants" and elect the retirement coverage checked in the box below. I understand that my election is irrevocable as long as
I am employed with the Department of Defense without a break in service (i.e., separation from Federal employment of 3 days
or less). I also understand that this election will not be retroactive and will become effective the first day of the first pay period
following receipt of this form in the human resources office stated on the notice.
(X one box only)
a. I elect full annuity and salary during this period of reemployment with the Department of Defense. I understand that this
means that no retirement deductions will be made from my salary, nor will I have the ability to pay a deposit for such
deductions upon separation; that I will be ineligible to participate in the Thrift Savings Plan; that this period of service is
ineligible for retirement credit; and that I will be ineligible for a supplemental or redetermined annuity upon separation.
b. I elect salary offset and FERS and social security deductions from my pay, as appropriate. I understand that this means
that my annuity will continue; that my pay will be reduced by the amount of annuity paid for my period of reemployment; that
FERS and social security deductions will be withheld from my pay, as appropriate; that I may be eligible for a supplemental
or redetermined annuity based on how long I work during the reemployment period; and that I am eligible to participate in the
Thrift Savings Plan.
3. REEMPLOYED ANNUITANT'S SIGNATURE
4. DATE SIGNED
DD FORM 2938, DEC 2008
Adobe Designer 8.0