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APPLICATION TO MAKE SERVICE CREDIT PAYMENT

Civilian protection orders must be enforced on base. Many abused individuals have both a military protection order and a civilian protection order. If you are thinking about getting a military protection order, there are a few things you should consider. Remember that reporting incidents of abuse to military personnel, other than clergy, is not typically confidential. Anything you say to military personnel regarding violence or abuse to yourself or your children must be reported to command staff. If you need to tell someone something confidential, ask the person if your conversation is protected by confidentiality requirements | Federal Employees Retirement System Application to Make Service Credit Payment Federal Employees Retirement System To avoid a delay in processing your claim 1. Read the attached information carefully. 2. Type or print in ink. 3. Complete Part A in full. If you are currently a Federal employee have your employing agency complete Part B. Form Approved OMB No. 3206-0134 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 employed including bureau branch or division 6. Social Security Number 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 or the Civil Service Retirement System CSRS j Yes complete items 9a and 9b No 9a. Typ e of application Service credit payment Refund Return of excess deductions Retirement 9b.Claim number s if available 10. I am applying to make a service credit payment for _l Civilian Service Complete item 10 Military Service Go to item 11 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 including bureau branch or division where employed Location of Employment city and state Title of Position Periods of Service Check whether deductions were not withheld withheld and refunded or withheld and remain to your credit Put a check mark 9 in the boxes below next to the periods of service you want to pay for. If you do not want to pay for a specific period of service leave the box blank. Beginning Date mm dd yyyy Ending Date mm dd yyyy Not Withheld Withheld and Refunded Withheld and Not Refunded 11. Are deductions for the Federal Employees Retirement System now being withheld from your salary Yes Go to item 13 1 No