Application To Make Voluntary Contributions

Download a blank fillable Application To Make Voluntary Contributions in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Application To Make Voluntary Contributions with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

APPLICATION TO MAKE VOLUNTARY CONTRIBUTIONS
(1) Type or print in ink.
(2) Answer all the questions.
Civil Service Retirement System
Civil Service
Retirement System
1. Name (Last, first, middle)
2. Date of birth (mm/dd/yyyy)
3. Social Security Number
4. Address (Number, street, city, state, and ZIP code)
5. List all other names you have used (Include maiden name, if applicable.)
6a.
Do you have any civilian government service during
Yes
Yes
6b. Have you made a deposit to the Civil Service Retirement and
which no Civil Service Retirement deductions were
Disability Fund to cover this non-deduction service?
taken from your salary?
No
No
7a.
Do you have any service during which Civil Service
Yes
Yes
7b. Have you made a redeposit to the Civil Service Retirement and
Retirement deductions were taken from your salary and
Disability Fund of the amount refunded to you?
later refunded to you?
No
No
8a.
Have you ever made voluntary contributions and later
Yes
Yes
8b. Have you since been separated from the government service for a
received a refund of them?
period of more than 3 calendar days?
No
No
Agency Certification
If your answer to question 6b, 7b, or 8b is "No", do not file this application.
I certify that the applicant is an employee of the agency shown below, is in a
See the attached information.
position subject to the Civil Service Retirement System,
and has answered question 6a correctly.
Agency address
Signature
I hereby apply to make voluntary contributions to the Civil Service Retirement and
Disability Fund. I am employed in a position subject to the Civil Service Retirement
Official title
System or I am an applicant for retirement under the Civil Service Retirement
System. I have read the information on the attached page.
Applicant's signature (Do not print)
Date
Telephone number
Date
(
)
Privacy Act Statement
Title 5, U.S. Code, Chapter 83, Civil Service Retirement authorizes the solicitation of this information. The data you furnish will be used to identify records properly associated with this application, to
obtain additional information if necessary, and to determine if you are eligible to make voluntary contributions to the Civil Service Retirement and Disability Fund. This 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 to determine
and issue benefits under their programs 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 use of the Social Security Number. Failure to supply all of the requested information may delay or
prevent approval of your application.
You need to read the attached information so that you understand the effect of making voluntary contributions. Ask your personnel office if you are employed and need more information. If a personnel
office is not available, contact the Office of Personnel Management at the address given or call 1-888-767-6738 (TDD: 1-800-878-5707).
U.S. Office of Personnel Management
See the Attached Information Sheet
SF 2804
CSRS and FERS Handbook for Personnel and Payroll Offices
PRINT
CLEAR
SAVE
NSN 7540-00-634-4253
2804-110
Revised July 2006
The July 1999 edition is usable. All other previous editions are unusable.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3