**Department of Energy**

**Environmental Management**

**Consolidated Business Center (EMCBC)**

**Office of Human Resources**

**250 East 5^th^ Street, Suite 500**

#### Cincinnati, OH 45202

**Phone: 513-246-0515**

**Fax: 513-246-0525**

REQUEST FOR RETIREMENT ANNUITY ESTIMATE

The purpose of this form is to gather information that pertains
specifically to you. A Benefits Specialist needs this in order to

provide you with the best estimate possible. It is important that these
questions be answered to the best of your ability. Some

can be verified in your Official Personnel File, while others cannot.
The information you provide can have significant impact on

your benefit entitlements. If you have any questions, please contact
Robin Campbell at 513-246-0515 or via email at
[robin.campbell@emcbc.doe.gov]{.underline}

**Please provide the following information:**

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SSN:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date of Birth:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

MM/DD/YY

Service Computation Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Retirement System:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Mailing Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Organization:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Location:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone Number:
(W)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(H)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (Fax)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Position Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Pay Plan/Series/Grade:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Projected Retirement Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

# 

Hours of sick leave you expect to have at retirement (**CSRS ONLY**):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Type of retirement benefits applying for: (**circle one**)

a\. Voluntary

b.  Voluntary Early VSIP Calculation: \_\_\_\_\_\_\_Yes \_\_\_\_\_\_\_No

c.  Disability

d.  Discontinued Service

e.  Minimum Retirement Age plus 10 years of service

Will you elect to take Health Insurance into Retirement?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Code: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Will you elect to take Supplemental Dental into Retirement?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Code: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Will you elect to take Supplemental Vision into Retirement?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Code: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Will you elect to take Life Insurance into Retirement?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Code: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(If you elect to continue coverage into retirement, please circle your
choice from the following alternative selections

with respect to your basic life insurance coverage.) Your life insurance
code can be obtained from your Leave & Earnings Statement or block 27 of
your most recent SF-50, Notification of Personnel Action.

a\. 75% Reduction b. 50% Reduction c. No Reduction

[OPTION A]{.underline} Continue into retirement: \_\_\_\_\_\_\_Yes
\_\_\_\_\_\_\_No

[OPTION B]{.underline} Number of multiples you want to continue:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_Full Reduction [OR]{.underline} \_\_\_\_\_\_\_\_ No
Reduction

Page 1 of 2

### 

### OPTION C Number of multiples you want to continue: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###  \_\_\_\_\_\_\_\_ Full Reduction OR \_\_\_\_\_\_\_\_\_No Reduction

### 

## Marital Status Circle One

-   Are you married? **Yes No**

-   **If yes**, spouse's name:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   **If yes**, will you elect a survivor annuity for a current and/or
    former spouse? **Yes No**

-   Do you have a court order awarding a survivor annuity to a former
    spouse,

from whom you were divorced on or after May 7, 1985? **Yes No**

## Military Service

-   Were you in the military? **Yes No**

-   Did you serve on active duty after 1956? **Yes No N/A**

-   **If so**, have you made the deposit for this service? **Yes No
    N/A**

-   **If not**, do you plan to make the deposit? **Yes No N/A**

-   If you are a military retiree, do you plan to waive your military
    retired pay in

order to combine this service with your civilian service? **Yes No N/A**

-   Is there a copy of your Military Discharge (DD 214) in your official

personnel folder (OPF)? **Yes No N/A**

## Other Types of Civilian Services and Basic Pay Information

-   Have you performed **part time** service after April 6, 1986? **Yes
    No**

-   Have you worked as an **intermittent** employee? **Yes No**

-   Have you served under a **temporary appointment**? **Yes No**

-   **If yes**, have you paid the deposit for that service? **Yes No
    N/A**

-   Have you worked as a **NAF** (Nonappropriated Funds) employee? **Yes
    No**

-   Have you had more than 6 months of Leave Without Pay

(LWOP) during any part of the last three years? **Yes No**

-   Have you resigned from a federal job, applied for and received a
    refund of **Yes No**

your retirement contributions? (**If yes**, please provide the
approximate

amount you withdrew and when (month/year) you received the money, if

possible):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   Have you ever received severance pay? **Yes No**

-   **If so**, when and how much?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
    **N/A**

-   Federal Tax Withholding -- **Single** or **Married**

-   Federal Tax Withholding -- **Number of Exemptions**:
    \_\_\_\_\_\_\_\_\_

Page 2 of 2 - Revised 03/2007