[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

**National Finance Center (NFC)**

Office of Personnel Management (OPM)

FEHB Centralized Enrollment

> Clearinghouse Project

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

##### Version 1.0

Approved By:

October 9, 2001

\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Abby L. Block, OPM, Assistant Director for
Insurance Programs Date

July 18, 2001

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Elizabeth W. Rafferty, NFC, Project Manager Date

July 18, 2001

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Roderick Keith, NFC, Project Executive Date

**Table of Contents**

1 2809 FILE LAYOUT

Page 2

1.1 Header Record Layout Page 4

1.2 Footer Record Layout Page 5

1.3 Null Record
Layout....................................................................Page
7

1.4 Corrective Action Layout - 2809 File Page

8

**1 2809 FILE LAYOUT**

> This document describes the data elements that are included in the
> Form 2809 Corrective Action File Layout that will be created by the
> National Finance Center (NFC) based upon the corrective action data
> entered into the Federal Employees Health Benefits (FEHB) Centralized
> Enrollment Clearinghouse System (CLER). The agency will enter 2809
> corrective action data using the Forms Screen Category on the CLER Web
> site. Office of Personnel Management (OPM) data hub located in Macon,
> Georgia, will distribute the data contained in the corrective action
> file layout to the carriers. The carriers will use the information to
> reconcile their records.
>
> Each transmission file will include a header record, detail record(s),
> and a footer record. These files will be in American Standard Code for
> Information Interchange (ASCII) text format with no other embedded
> data types or delimiters.

If you have specific technical questions about this document you can
contact:

Greg Kidd

504-255-2232

E-mail: <greg.kidd@usda.gov>

For requirements-related questions, please contact:

Sheila Morgan

504-255-6252

E-mail: [sheila.morgan@usda.gov](mailto:Sheila.morgan@usda.gov)

> If you have specific technical questions about connectivity to the
> FEHB hub at Macon, Georgia, please contact:

Chris Selle

478-744-2115

E-mail: <crselle@opm.gov>

> The following table describes the format for the 2809 record layouts
> that will be generated by the NFC and transmitted to the OPM Macon,
> Georgia, data hub for breakdown and transmission to the carriers. The
> data will be obtained from user input provided via CLER Web screens.
> The Web screen specifications document will detail the input
> requirements for the corrective action file (2809) data.

+-------------------+--------------------------------------------------+
| **COLUMN          | **COLUMN CONTENT**                               |
| HEADING**         |                                                  |
+===================+==================================================+
| \#                | Field number                                     |
+-------------------+--------------------------------------------------+
| TYPE/SIZE         | The data will be in ASCII format. This will      |
|                   | specify whether the values are alpha, numeric,   |
|                   | or alphanumeric and the length of the field.     |
+-------------------+--------------------------------------------------+
| COBOL             | COBOL data type and size                         |
+-------------------+--------------------------------------------------+
| VALUE, FORMAT,    | Value = indicates permissible field values       |
| NOTES             |                                                  |
|                   | Format = indicated justification, padding, etc.  |
|                   |                                                  |
|                   | Notes = special field considerations, examples,  |
|                   | or miscellaneous                                 |
+-------------------+--------------------------------------------------+
| REQUIRED          | Required column content indicates what data will |
|                   | be Required, Optional, or Conditional on the     |
|                   | CLER Web input screens.                          |
+-------------------+--------------------------------------------------+
| DEFINITION        | The Definition column describes the value,       |
|                   | format, and notes that will be provided to the   |
|                   | user when inputting the data on the CLER Web     |
|                   | screens.                                         |
+-------------------+--------------------------------------------------+

## 1.1 Header Record Layout

This record is generated by NFC and included in each file transmission
to OPM-Macon. It is the first record in all data transmissions to
OPM-Macon. This information is not sent to the FEHB carriers but is used
by OPM-Macon for complete data transfer verification.

# 

+---+------------+---+----+---------------+------+--------------------+
| * | **NAME**   | * | *  | **VALUE,      | **RE | **DEFINITION**     |
| * |            | * | *C | FORMAT,       | QUIR |                    |
| \ |            | T | OB | NOTES**       | ED** |                    |
| # |            | Y | OL |               |      |                    |
| * |            | P | ** |               |      |                    |
| * |            | E |    |               |      |                    |
|   |            | / |    |               |      |                    |
|   |            | S |    |               |      |                    |
|   |            | I |    |               |      |                    |
|   |            | Z |    |               |      |                    |
|   |            | E |    |               |      |                    |
|   |            | * |    |               |      |                    |
|   |            | * |    |               |      |                    |
+===+============+===+====+===============+======+====================+
| 1 | R          | T | X  | Value =       | Requ | This defines       |
|   | ECORD_TYPE | e | (1 | literal       | ired | whether the record |
|   |            | x | 7) | \"BATCH       |      | will be at the top |
|   |            | t |    | HEADER FOR\"  |      | of the file        |
|   |            | , |    |               |      | (header), bottom   |
|   |            | 1 |    | Format = Left |      | of the file        |
|   |            | 7 |    | justify, pad  |      | (footer), or just  |
|   |            |   |    | with a        |      | one of the         |
|   |            |   |    | trailing      |      | individual         |
|   |            |   |    | space         |      | enrollment         |
|   |            |   |    |               |      | records.           |
+---+------------+---+----+---------------+------+--------------------+
| 2 | FILE_ID    | T | X( | Value =       | Requ | With the literal   |
|   |            | e | 8) | literal "NFC" | ired | "NFC" plus the     |
|   |            | x |    | plus the      |      | quarter and year   |
|   |            | t |    | quarter and   |      | of the             |
|   |            | , |    | year of the   |      | reconciliation,    |
|   |            | 8 |    | r             |      | this field serves  |
|   |            |   |    | econciliation |      | as a unique        |
|   |            |   |    |               |      | identifier for     |
|   |            |   |    | Quarter: 1 =  |      | each transmission. |
|   |            |   |    | first quarter |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | 2 = second    |      |                    |
|   |            |   |    | quarter       |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | 3 = third     |      |                    |
|   |            |   |    | quarter       |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | 4 = fourth    |      |                    |
|   |            |   |    | quarter       |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | Year = YYYY   |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | Example:      |      |                    |
|   |            |   |    | NFC42001 is   |      |                    |
|   |            |   |    | the fourth    |      |                    |
|   |            |   |    | quarter in    |      |                    |
|   |            |   |    | the year      |      |                    |
|   |            |   |    | 2001.         |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| 3 | FILLER     | T | X( | Value = Pad   | Requ | This field is      |
|   |            | e | 2) | with spaces   | ired | reserved for       |
|   |            | x |    |               |      | future use.        |
|   |            | t |    |               |      |                    |
|   |            | , |    |               |      |                    |
|   |            | 2 |    |               |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| 4 | FILE_CRE   | T | X( | Value = The   | Requ | This is the date   |
|   | ATION_DATE | e | 8) | date the file | ired | that the file was  |
|   |            | x |    | was created   |      | created by NFC for |
|   |            | t |    |               |      | OPM-Macon.         |
|   |            | , |    | Format =      |      |                    |
|   |            | 8 |    | YYYYMMDD      |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| T |            | 3 | 35 |               |      |                    |
| O |            | 5 | C  |               |      |                    |
| T |            |   | ol |               |      |                    |
| A |            | B | um |               |      |                    |
| L |            | y | ns |               |      |                    |
|   |            | t |    |               |      |                    |
|   |            | e |    |               |      |                    |
|   |            | s |    |               |      |                    |
+---+------------+---+----+---------------+------+--------------------+

##  1.2 Footer Record Layout

This record is generated by NFC and included in each file transmission
to OPM-Macon. It is the last record in all data transmissions to
OPM-Macon. This information is not sent to the FEHB carriers but is used
by OPM-Macon for complete data transfer verification.

+---+------------+---+----+---------------+------+--------------------+
| * | **NAME**   | * | *  | **VALUE,      | **RE | **DEFINITION**     |
| * |            | * | *C | FORMAT,       | QUIR |                    |
| \ |            | T | OB | NOTES**       | ED** |                    |
| # |            | Y | OL |               |      |                    |
| * |            | P | ** |               |      |                    |
| * |            | E |    |               |      |                    |
|   |            | / |    |               |      |                    |
|   |            | S |    |               |      |                    |
|   |            | I |    |               |      |                    |
|   |            | Z |    |               |      |                    |
|   |            | E |    |               |      |                    |
|   |            | * |    |               |      |                    |
|   |            | * |    |               |      |                    |
+===+============+===+====+===============+======+====================+
| 1 | R          | T | X  | Value =       | Requ | This defines       |
|   | ECORD_TYPE | e | (1 | literal       | ired | whether the record |
|   |            | x | 7) | \"BATCH       |      | will be at the top |
|   |            | t |    | FOOTER FOR\"  |      | of the file        |
|   |            | , |    |               |      | (header), bottom   |
|   |            | 1 |    | Format = Left |      | of the file        |
|   |            | 7 |    | justify, pad  |      | (footer), or just  |
|   |            |   |    | with a        |      | one of the         |
|   |            |   |    | trailing      |      | individual         |
|   |            |   |    | space         |      | enrollment         |
|   |            |   |    |               |      | records.           |
+---+------------+---+----+---------------+------+--------------------+
| 2 | FILE_ID    | T | X( | Value =       | Requ | With the literal   |
|   |            | e | 8) | literal "NFC" | ired | "NFC" plus the     |
|   |            | x |    | plus the      |      | quarter and year   |
|   |            | t |    | quarter and   |      | of the             |
|   |            | , |    | year of the   |      | reconciliation,    |
|   |            | 8 |    | r             |      | this field serves  |
|   |            |   |    | econciliation |      | as a unique        |
|   |            |   |    |               |      | identifier for     |
|   |            |   |    | Quarter: 1 =  |      | each transmission. |
|   |            |   |    | first quarter |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | 2 = second    |      |                    |
|   |            |   |    | quarter       |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | 3 = third     |      |                    |
|   |            |   |    | quarter       |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | 4 = fourth    |      |                    |
|   |            |   |    | quarter       |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | Year = YYYY   |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | Example:      |      |                    |
|   |            |   |    | NFC42001 is   |      |                    |
|   |            |   |    | the fourth    |      |                    |
|   |            |   |    | quarter in    |      |                    |
|   |            |   |    | the year      |      |                    |
|   |            |   |    | 2001.         |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| 3 | FILLER     | T | X( | Value = Pad   | Requ | This field is      |
|   |            | e | 2) | with spaces   | ired | reserved for       |
|   |            | x |    |               |      | future use.        |
|   |            | t |    |               |      |                    |
|   |            | , |    |               |      |                    |
|   |            | 2 |    |               |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| 4 | RECO       | T | X( | Value =       | Requ | The literal        |
|   | RD_COUNT\_ | e | 9) | literal       | ired | "RECORDS:" will    |
|   |            | x |    | \"RECORDS:\"  |      | precede the        |
|   | INDICATOR  | t |    |               |      | numeric total of   |
|   |            | , |    | Format = Left |      | the                |
|   |            | 9 |    | justify, pad  |      | DATA_RECORD_COUNT. |
|   |            |   |    | with a        |      |                    |
|   |            |   |    | trailing      |      |                    |
|   |            |   |    | space         |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| 5 | DATA_RE    | T | X( | Value =       | Requ | This is the total  |
|   | CORD_COUNT | e | 8) | Record count, | ired | number of          |
|   |            | x |    | excluding     |      | corrective action  |
|   |            | t |    | Header and    |      | records (for all   |
|   |            | , |    | Footer        |      | carriers) included |
|   |            | 8 |    | records       |      | in the file minus  |
|   |            |   |    |               |      | the Header and     |
|   |            |   |    | Format =      |      | Footer records in  |
|   |            |   |    | Right         |      | this count.        |
|   |            |   |    | justify, pad  |      |                    |
|   |            |   |    | with leading  |      |                    |
|   |            |   |    | zeroes.       |      |                    |
|   |            |   |    |               |      |                    |
|   |            |   |    | Example:      |      |                    |
|   |            |   |    | 00001234      |      |                    |
|   |            |   |    | (1,234        |      |                    |
|   |            |   |    | corrective    |      |                    |
|   |            |   |    | action        |      |                    |
|   |            |   |    | records)      |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| 6 | FILLER     | T | X( | Value = Pad   | Requ | This field is      |
|   |            | e | 1) | with a space  | ired | reserved for       |
|   |            | x |    |               |      | future use.        |
|   |            | t |    |               |      |                    |
|   |            | , |    |               |      |                    |
|   |            | 1 |    |               |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| 7 | FILE_CRE   | T | X( | Value = The   | Requ | This is the date   |
|   | ATION_DATE | e | 8) | date the file | ired | that the file was  |
|   |            | x |    | was created   |      | created by NFC for |
|   |            | t |    |               |      | OPM-Macon.         |
|   |            | , |    | Format =      |      |                    |
|   |            | 8 |    | YYYYMMDD      |      |                    |
+---+------------+---+----+---------------+------+--------------------+
| T |            | 5 | 53 |               |      |                    |
| O |            | 3 | C  |               |      |                    |
| T |            |   | ol |               |      |                    |
| A |            | B | um |               |      |                    |
| L |            | y | ns |               |      |                    |
|   |            | t |    |               |      |                    |
|   |            | e |    |               |      |                    |
|   |            | s |    |               |      |                    |
+---+------------+---+----+---------------+------+--------------------+

## 1.3 Null Record Layout

## 

NFC will transmit a file to OPM-Macon once each quarterly cycle. If
there are no data records for a particular quarter, the transmission
will consist of a Header Record, a Null Record, and a Footer Record.

The Footer Record Layout will contain all zeroes for the
DATA_RECORD_COUNT field.

The Null record will contain 999999 in the NULL_RECORD_INDICATOR field,
and the extraction date in the FILE_CREATION_DATE field.

Example of a Null Record File created on June 1, 2002:

BATCH HEADER FOR NFC22002 20020601

99999920020601

BATCH FOOTER FOR NFC22002 RECORDS: 00000000 20020601

# 

+---+--------------+---+----+------------------+------+---------------+
| * | **NAME**     | * | *  | **VALUE, FORMAT, | **RE | *             |
| * |              | * | *C | NOTES**          | QUIR | *DEFINITION** |
| \ |              | T | OB |                  | ED** |               |
| # |              | Y | OL |                  |      |               |
| * |              | P | ** |                  |      |               |
| * |              | E |    |                  |      |               |
|   |              | / |    |                  |      |               |
|   |              | S |    |                  |      |               |
|   |              | I |    |                  |      |               |
|   |              | Z |    |                  |      |               |
|   |              | E |    |                  |      |               |
|   |              | * |    |                  |      |               |
|   |              | * |    |                  |      |               |
+---+--------------+---+----+------------------+------+---------------+
| 1 | NULL_RECO    | T | X( | Value = literal  | Requ | This field is |
|   | RD_INDICATOR | e | 6) | \"999999\"       | ired | completed     |
|   |              | x |    |                  |      | when there    |
|   |              | t |    |                  |      | are no data   |
|   |              | , |    |                  |      | records for a |
|   |              | 6 |    |                  |      | particular    |
|   |              |   |    |                  |      | quarter.      |
+---+--------------+---+----+------------------+------+---------------+
| 2 | FILE_C       | T | X( | Value = Date the | Requ | This is the   |
|   | REATION_DATE | e | 8) | file was created | ired | date that the |
|   |              | x |    |                  |      | file was      |
|   |              | t |    | Format =         |      | created by    |
|   |              | , |    | YYYYMMDD         |      | NFC for       |
|   |              | 8 |    |                  |      | OPM-Macon.    |
+---+--------------+---+----+------------------+------+---------------+
| T |              | 1 | 14 |                  |      |               |
| O |              | 4 | C  |                  |      |               |
| T |              |   | ol |                  |      |               |
| A |              | B | um |                  |      |               |
| L |              | y | ns |                  |      |               |
|   |              | t |    |                  |      |               |
|   |              | e |    |                  |      |               |
|   |              | s |    |                  |      |               |
+---+--------------+---+----+------------------+------+---------------+

***1.4 Corrective Action File Layout - 2809 File***

+---+---------+---+---+--------------------+-----+-------------------+
| \ | ##      | # | # | # VA               | #   | # DEFINITION      |
| # | ## NAME |   |   | LUE, FORMAT, NOTES |  RE |                   |
|   |         | T | C |                    | QUI |                   |
|   |         | Y | O |                    | RED |                   |
|   |         | P | B |                    |     |                   |
|   |         | E | O |                    |     |                   |
|   |         | / | L |                    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         | # |   |                    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         | S |   |                    |     |                   |
|   |         | I |   |                    |     |                   |
|   |         | Z |   |                    |     |                   |
|   |         | E |   |                    |     |                   |
+===+=========+===+===+====================+=====+===================+
| 1 | NATU    | T | X | Value = START,     | Re  | This term         |
|   | RE_OF\_ | e | ( | CHANGE, STOP, or   | qui | indicates the     |
|   |         | x | 6 | SUSPEND            | red | nature of the     |
|   | TRAN    | t | ) |                    |     | transaction to be |
|   | SACTION | , |   | START = This term  |     | taken on the FEHB |
|   |         | 6 |   | is used when an    |     | account.          |
|   |         |   |   | individual enrolls |     |                   |
|   |         |   |   | in the FEHB        |     |                   |
|   |         |   |   | Program.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | CHANGE = This term |     |                   |
|   |         |   |   | is used when an    |     |                   |
|   |         |   |   | enrollee changes   |     |                   |
|   |         |   |   | his/her current    |     |                   |
|   |         |   |   | enrollment         |     |                   |
|   |         |   |   | election to        |     |                   |
|   |         |   |   | another plan or    |     |                   |
|   |         |   |   | another option     |     |                   |
|   |         |   |   | within a plan.     |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | STOP (CANCEL) =    |     |                   |
|   |         |   |   | This term is used  |     |                   |
|   |         |   |   | when an enrollee   |     |                   |
|   |         |   |   | chooses to         |     |                   |
|   |         |   |   | discontinue        |     |                   |
|   |         |   |   | his/her enrollment |     |                   |
|   |         |   |   | in the FEHB        |     |                   |
|   |         |   |   | Program (i.e.,     |     |                   |
|   |         |   |   | STOP or CANCEL).   |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | SUSPEND = This     |     |                   |
|   |         |   |   | term is used when  |     |                   |
|   |         |   |   | an enrollee        |     |                   |
|   |         |   |   | suspends his/her   |     |                   |
|   |         |   |   | enrollment because |     |                   |
|   |         |   |   | (1) the enrollee   |     |                   |
|   |         |   |   | is going to be     |     |                   |
|   |         |   |   | continuously       |     |                   |
|   |         |   |   | covered as a       |     |                   |
|   |         |   |   | family member      |     |                   |
|   |         |   |   | under another      |     |                   |
|   |         |   |   | person's FEHB      |     |                   |
|   |         |   |   | enrollment, or (2) |     |                   |
|   |         |   |   | the enrollee is    |     |                   |
|   |         |   |   | enrolling in a     |     |                   |
|   |         |   |   | Medicare Managed   |     |                   |
|   |         |   |   | Care Plan (MMCP).  |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Format = Left      |     |                   |
|   |         |   |   | justify, pad with  |     |                   |
|   |         |   |   | trailing spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | E       | T | X | Value = Enrollee's | Re  | This is the       |
|   | NROLLEE | e | ( | last name          | qui | surname of the    |
|   | _LAST\_ | x | 2 |                    | red | enrollee. An      |
|   |         | t | 5 | Format = Left      |     | enrollee must     |
|   | NAME    | , | ) | justify, no        |     | always have a     |
|   |         | 2 |   | punctuation, pad   |     | last name. If     |
|   |         | 5 |   | with trailing      |     | there is a case   |
|   |         |   |   | spaces             |     | of an enrollee    |
|   |         |   |   |                    |     | having only one   |
|   |         |   |   |                    |     | name (e.g.,       |
|   |         |   |   |                    |     | Cher), then that  |
|   |         |   |   |                    |     | one name must be  |
|   |         |   |   |                    |     | placed in the     |
|   |         |   |   |                    |     | last name field.  |
|   |         |   |   |                    |     | If the enrollee   |
|   |         |   |   |                    |     | has a title       |
|   |         |   |   |                    |     | (e.g., Jr, Sr, I, |
|   |         |   |   |                    |     | II, III), it      |
|   |         |   |   |                    |     | should be entered |
|   |         |   |   |                    |     | after the last    |
|   |         |   |   |                    |     | name without      |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | EN      | T | X | Value = Enrollee's | Co  | First name of the |
|   | ROLLEE_ | e | ( | first name         | ndi | enrollee. This    |
|   | FIRST\_ | x | 1 |                    | tio | must be provided  |
|   |         | t | 7 | Format = Left      | nal | except in the     |
|   | NAME    | , | ) | justify, no        |     | rare circumstance |
|   |         | 1 |   | punctuation, pad   |     | that an           |
|   |         | 7 |   | with trailing      |     | individual only   |
|   |         |   |   | spaces             |     | has one name      |
|   |         |   |   |                    |     | (e.g., Cher).     |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | ENR     | T | X | Value = Enrollee's | Co  | This is the       |
|   | OLLEE\_ | e | ( | middle initial     | ndi | enrollee's middle |
|   |         | x | 1 |                    | tio | initial. If       |
|   | MIDDLE_ | t | ) | Format = No        | nal | enrollee uses one |
|   | INITIAL | , |   | punctuation        |     | name, or if       |
|   |         | 1 |   |                    |     | enrollee does not |
|   |         |   |   | Note = If blank,   |     | have a middle     |
|   |         |   |   | pad with a space   |     | name or initial,  |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | blank.            |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | SOC     | T | X | Value = Enrollee's | Co  | This is the       |
|   | IAL_SEC | e | ( | Social Security    | ndi | enrollee's SSN or |
|   | URITY\_ | x | 9 | Number (SSN) or    | tio | other number that |
|   |         | t | ) | other number that  | nal | is used to        |
|   | NUMBER  | , |   | is used to         |     | identify the      |
|   |         | 9 |   | identify the       |     | enrollee such as  |
|   |         |   |   | enrollee           |     | the OPM-assigned  |
|   |         |   |   |                    |     | Civil Service     |
|   |         |   |   | Format = Left      |     | Annuitant (CSA)   |
|   |         |   |   | justify, no        |     | number or the     |
|   |         |   |   | dashes, pad with   |     | Civil Service     |
|   |         |   |   | trailing spaces    |     | Final (CSF)       |
|   |         |   |   |                    |     | number. If the    |
|   |         |   |   | Example: 123456789 |     | enrollee does not |
|   |         |   |   |                    |     | want his/her SSN  |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | DATE_O  | T | X | Value = Date of    | Re  | This is the       |
|   | F_BIRTH | e | ( | enrollee's birth   | qui | enrollee's date   |
|   |         | x | 8 |                    | red | of birth.         |
|   |         | t | ) | Format = YYYYMMDD  |     |                   |
|   |         | , |   |                    |     |                   |
|   |         | 8 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | DOMEST  | T | X | Value = The first  | Co  | This is the first |
|   | IC_OR\_ | e | ( | line of the        | ndi | line of the       |
|   |         | x | 3 | enrollee's         | tio | enrollee's        |
|   | FOREIGN | t | 5 | domestic or        | nal | domestic or       |
|   | _HOME\_ | , | ) | foreign street     |     | foreign street,   |
|   |         | 3 |   | address            |     | apartment number, |
|   | S       | 5 |   |                    |     | PO box, rural     |
|   | TREET_1 |   |   | Format = Left      |     | route, etc., as   |
|   |         |   |   | justify, no        |     | applicable.       |
|   |         |   |   | punctuation, pad   |     |                   |
|   |         |   |   | with trailing      |     | This field is     |
|   |         |   |   | spaces             |     | required except   |
|   |         |   |   |                    |     | in rare cases     |
|   |         |   |   | Example: Route 1   |     | where the address |
|   |         |   |   | Box 618B           |     | does not contain  |
|   |         |   |   |                    |     | a street or PO    |
|   |         |   |   | Note = If blank,   |     | box (i.e., John   |
|   |         |   |   | pad with spaces    |     | Doe, Modale, IA   |
|   |         |   |   |                    |     | 51556).           |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | DOMEST  | T | X | Value = Second     | Co  | This is the       |
|   | IC_OR\_ | e | ( | line of enrollee's | ndi | second line of    |
|   |         | x | 3 | domestic or        | tio | the enrollee's    |
|   | FOREIGN | t | 5 | foreign street     | nal | domestic or       |
|   | _HOME\_ | , | ) | address            |     | foreign street,   |
|   |         | 3 |   |                    |     | apartment number, |
|   | S       | 5 |   | Format = Left      |     | PO box, rural     |
|   | TREET_2 |   |   | justify, no        |     | route, etc., as   |
|   |         |   |   | punctuation, pad   |     | applicable.       |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | This field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   | Note = If blank,   |     | in rare cases     |
|   |         |   |   | pad with spaces    |     | where the address |
|   |         |   |   |                    |     | does not contain  |
|   |         |   |   |                    |     | a street or PO    |
|   |         |   |   |                    |     | box (i.e., John   |
|   |         |   |   |                    |     | Doe, Modale, IA   |
|   |         |   |   |                    |     | 51556).           |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | DOMEST  | T | X | Value = Third line | Co  | This is the third |
|   | IC_OR\_ | e | ( | of enrollee's      | ndi | line of the       |
|   |         | x | 3 | domestic or        | tio | enrollee's        |
|   | FOREIGN | t | 5 | foreign street     | nal | domestic or       |
|   | _HOME\_ | , | ) | address            |     | foreign street,   |
|   |         | 3 |   |                    |     | apartment number, |
|   | S       | 5 |   | Format = Left      |     | PO box, rural     |
|   | TREET_3 |   |   | justify, no        |     | route, etc., as   |
|   |         |   |   | punctuation, pad   |     | applicable.       |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | This field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   | Note = If blank,   |     | in rare cases     |
|   |         |   |   | pad with spaces    |     | where the address |
|   |         |   |   |                    |     | does not contain  |
|   |         |   |   |                    |     | a street or PO    |
|   |         |   |   |                    |     | box (i.e., John   |
|   |         |   |   |                    |     | Doe, Modale, IA   |
|   |         |   |   |                    |     | 51556).           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DOMEST  | T | X | Value = Enrollee's | Re  | This is the       |
| 0 | IC_OR\_ | e | ( | domestic or        | qui | domestic or       |
|   |         | x | 2 | foreign city name  | red | foreign city for  |
|   | FOR     | t | 3 |                    |     | the enrollee's    |
|   | EIGN_HO | , | ) | Format: = Left     |     | address.          |
|   | ME_CITY | 2 |   | justify, pad with  |     |                   |
|   |         | 3 |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Example: Macon     |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | D       | T | X | Value = Enrollee's | Co  | This is the       |
| 1 | OMESTIC | e | ( | domestic state     | ndi | abbreviation of   |
|   | _HOME\_ | x | 2 | abbreviation       | tio | the domestic      |
|   |         | t | ) |                    | nal | state for the     |
|   | STATE   | , |   | Example: GA for    |     | enrollee's        |
|   |         | 2 |   | Georgia            |     | address.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     | Required if       |
|   |         |   |   | pad with spaces    |     | address is        |
|   |         |   |   |                    |     | domestic. If the  |
|   |         |   |   |                    |     | address is        |
|   |         |   |   |                    |     | foreign, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FOREIG  | T | X | Value = Enrollee's | Co  | This is the name  |
| 2 | N_COUNT | e | ( | foreign country    | ndi | of the enrollee's |
|   | RY_NAME | x | 2 | name               | tio | foreign country.  |
|   |         | t | 3 |                    | nal |                   |
|   |         | , | ) | Format = Left      |     | Required if       |
|   |         | 2 |   | justify, pad with  |     | address is        |
|   |         | 3 |   | trailing spaces    |     | foreign. If the   |
|   |         |   |   |                    |     | address is        |
|   |         |   |   | Example: Canada    |     | domestic, this    |
|   |         |   |   |                    |     | field is blank.   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | HOME_Z  | T | X | Value = Domestic:  | Re  | This is the       |
| 3 | IP_OR\_ | e | ( | 5 digit            | qui | domestic ZIP code |
|   |         | x | 1 | mandatory + 4      | red | or foreign postal |
|   | FO      | t | 1 | optional Foreign:  |     | code for the      |
|   | REIGN_P | , | ) | Postal Code        |     | enrollee's        |
|   | OSTAL\_ | 1 |   |                    |     | address.          |
|   |         | 1 |   | Examples:          |     |                   |
|   | CODE    |   |   | Domestic: 31206 or |     |                   |
|   |         |   |   | 312064204;         |     |                   |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Format = Left      |     |                   |
|   |         |   |   | justify, no        |     |                   |
|   |         |   |   | dashes, pad with   |     |                   |
|   |         |   |   | trailing spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | COUNT   | T | X | Value = Valid U.S. | Op  | This code         |
| 4 | RY_CODE | e | ( | Postal Service     | tio | identifies the    |
|   |         | x | 3 | country code       | nal | foreign country   |
|   |         | t | ) |                    |     | for the           |
|   |         | , |   | Note = If blank,   |     | enrollee's        |
|   |         | 3 |   | pad with spaces    |     | address.          |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | SEX     | T | X | Value = M or F     | Re  | This code         |
| 5 |         | e | ( |                    | qui | indicates the     |
|   |         | x | 1 | M = male           | red | enrollee's sex.   |
|   |         | t | ) |                    |     |                   |
|   |         | , |   | F = female         |     |                   |
|   |         | 1 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | ENR     | T | X | Value = Y or N     | Re  | This code         |
| 6 | OLLEE\_ | e | ( |                    | qui | indicates the     |
|   |         | x | 1 | Y = yes            | red | enrollee's        |
|   | MAR     | t | ) |                    |     | marital status.   |
|   | RIAGE\_ | , |   | N = no             |     |                   |
|   |         | 1 |   |                    |     |                   |
|   | IN      |   |   |                    |     |                   |
|   | DICATOR |   |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | ENRO    | T | X | Value = Enrollee's | Op  | This is the       |
| 7 | LLEE_DA | e | ( | daytime area code  | tio | enrollee's        |
|   | YTIME\_ | x | 1 | and phone number   | nal | telephone number. |
|   |         | t | 7 |                    |     |                   |
|   | PHONE   | , | ) | Format = Left      |     |                   |
|   |         | 1 |   | justify, no dashes |     |                   |
|   |         | 7 |   | or spaces, pad     |     |                   |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Example:           |     |                   |
|   |         |   |   | 9127442286         |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FILLER  | T | X | Value = Pad with   | Re  | Reserved for      |
| 8 |         | e | ( | spaces             | qui | future use.       |
|   |         | x | 7 |                    | red |                   |
|   |         | t | ) |                    |     |                   |
|   |         | , |   |                    |     |                   |
|   |         | 7 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | NAME_   | T | X | Value = Name of    | Co  | This is the name  |
| 9 | OF_PLAN | e | ( | the FEHB health    | ndi | of the FEHB       |
|   |         | x | 3 | insurance plan     | tio | health insurance  |
|   |         | t | 5 |                    | nal | plan in which the |
|   |         | , | ) | Format = Left      |     | employee is       |
|   |         | 3 |   | justify, no        |     | enrolling.        |
|   |         | 5 |   | punctuation, pad   |     |                   |
|   |         |   |   | with trailing      |     | If                |
|   |         |   |   | spaces             |     | NATU              |
|   |         |   |   |                    |     | RE_OF_TRANSACTION |
|   |         |   |   | Note = If blank,   |     | is START or       |
|   |         |   |   | pad with spaces    |     | CHANGE, this      |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If it   |
|   |         |   |   |                    |     | is STOP or        |
|   |         |   |   |                    |     | SUSPEND, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEHB_E  | T | X | Value = Positions  | Co  | This code defines |
| 0 | NROLLME | e | ( | 1 and 2 equal the  | ndi | the plan and      |
|   | NT_CODE | x | 3 | plan; 3^rd^        | tio | option of the     |
|   |         | t | ) | position is the    | nal | enrollee.         |
|   |         | , |   | plan option        |     |                   |
|   |         | 3 |   |                    |     | If                |
|   |         |   |   | Note = If blank,   |     | NATU              |
|   |         |   |   | pad with spaces    |     | RE_OF_TRANSACTION |
|   |         |   |   |                    |     | is START or       |
|   |         |   |   |                    |     | CHANGE, this      |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If it   |
|   |         |   |   |                    |     | is STOP or        |
|   |         |   |   |                    |     | SUSPEND, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 1 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (1) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_1  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | Family Member (1) |
|   |         |   |   | Note = If blank,   |     | information is    |
|   |         |   |   | pad with spaces    |     | required if the   |
|   |         |   |   |                    |     | FEH               |
|   |         |   |   |                    |     | B_ENROLLMENT_CODE |
|   |         |   |   |                    |     | is for self and   |
|   |         |   |   |                    |     | family coverage.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   |                    |     | surname of the    |
|   |         |   |   |                    |     | enrollee's family |
|   |         |   |   |                    |     | member (1). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 2 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (1) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_1  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (1) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 3 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (1) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_1 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (1) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 4 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (1) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_1 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (1) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 5 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_1 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (1) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (1) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 6 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (1) |
|   | CODE_1  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (1) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 7 | AMILY\_ | e | ( | or 5               | ndi | (1) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_1 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 8 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_1 | x | 9 |                    | nal | family member (1) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (1) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 2 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 9 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (2) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_2  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (2). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 0 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (2) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_2  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (2) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 1 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (2) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_2 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (2) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 2 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (2) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_2 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (2) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 3 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_2 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (2) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (2) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 4 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (2) |
|   | CODE_2  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (2) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If Family member  |
| 5 | AMILY\_ | e | ( | or 5               | ndi | (2) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_2 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 6 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_2 | x | 9 |                    | nal | family member (2) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (2) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 7 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (3) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_3  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (3). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 8 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (3) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_3  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (3) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 3 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 9 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (3) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_3 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (3) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 0 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (3) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_3 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (3) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 1 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_3 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (3) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (3) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 2 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (3) |
|   | CODE_3  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (3) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 3 | AMILY\_ | e | ( | or 5               | ndi | (3) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_3 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 4 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_3 | x | 9 |                    | nal | family member (3) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (3) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 5 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (4) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_4  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (4). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 6 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (4) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_4  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (4) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 7 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (4) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_4 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (4) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 8 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (4) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_4 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (4) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 4 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 9 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_4 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (4) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (4) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 0 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (4) |
|   | CODE_4  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (4) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If Family member  |
| 1 | AMILY\_ | e | ( | or 5               | ndi | (4) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_4 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 2 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_4 | x | 9 |                    | nal | family member (4) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (4) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 3 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (5) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_5  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (5). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 4 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (5) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_5  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (5) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 5 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (5) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_5 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (5) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 6 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (5) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_5 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (5) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 7 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_5 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (5) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (5) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 8 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (5) |
|   | CODE_5  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (5) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 5 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 9 | AMILY\_ | e | ( | or 5               | ndi | (5) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_5 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 0 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_5 | x | 9 |                    | nal | family member (5) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (5) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 1 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (6) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_6  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (6). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 2 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (6) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_6  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (6) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 3 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (6) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_6 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (6) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 4 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (6) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_6 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (6) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 5 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_6 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (6) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (6) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 6 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (6) |
|   | CODE_6  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (6) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 7 | AMILY\_ | e | ( | or 5               | ndi | (6) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_6 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 8 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_6 | x | 9 |                    | nal | family member (6) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (6) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 6 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 9 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (7) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_7  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (7). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 0 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (7) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_7  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (7) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 1 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (7) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_7 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (7) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 2 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (7) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_7 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (7) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 3 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_7 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (7) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (7) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 4 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (7) |
|   | CODE_7  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (7) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 5 | AMILY\_ | e | ( | or 5               | ndi | (7) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_7 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 6 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_7 | x | 9 |                    | nal | family member (7) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (7) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 7 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (8) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_8  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (8). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 8 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (8) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_8  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (8) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 7 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 9 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (8) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_8 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (8) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 0 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (1) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_8 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (8) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 1 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_8 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (8) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (8) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 2 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (8) |
|   | CODE_8  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (8) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 3 | AMILY\_ | e | ( | or 5               | ndi | (8) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_8 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 4 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_8 | x | 9 |                    | nal | family member (8) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (8) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 5 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (9) who is |
|   | _LAST\_ | , | ) | justify, no        |     | e                 |
|   |         | 2 |   | punctuation, pad   |     | nrolled/enrolling |
|   | NAME_9  | 5 |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | This is the       |
|   |         |   |   | Note = If blank,   |     | surname of the    |
|   |         |   |   | pad with spaces    |     | enrollee's family |
|   |         |   |   |                    |     | member (9). The   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 6 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (9) who is |
|   | FIRST\_ | , | ) | Format = Left      |     | e                 |
|   |         | 1 |   | justify, no        |     | nrolled/enrolling |
|   | NAME_9  | 7 |   | punctuation, pad   |     | in FEHB.          |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If family member  |
|   |         |   |   |                    |     | (9) is used, and  |
|   |         |   |   | Note = If blank,   |     | the family member |
|   |         |   |   | pad with spaces    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 7 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member (9) |
|   | EMBER_M | , |   | Format = No        |     | who is            |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | IN      |   |   | Note = If blank,   |     | in FEHB.          |
|   | ITIAL_9 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (9) is used, and  |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 8 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (9) who is |
|   | POSTAL  | 1 |   | Examples:          |     | e                 |
|   | _CODE_9 |   |   | Domestic: 31206 or |     | nrolled/enrolling |
|   |         |   |   | 312064204;         |     | in FEHB.          |
|   |         |   |   | Foreign: H2W 1J5.  |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Format = Left      |     | (9) is used, this |
|   |         |   |   | justify, no        |     | field is helpful, |
|   |         |   |   | dashes, pad with   |     | but not required. |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 8 | FEH     | T | X | Value = Date of    | Co  | This is the date  |
| 9 | B_FAMIL | e | ( | family member's    | ndi | of birth of the   |
|   | Y_DOB_9 | x | 8 | birth              | tio | enrollee's family |
|   |         | t | ) |                    | nal | member (9) who is |
|   |         | , |   | Format: = YYYYMMDD |     | e                 |
|   |         | 8 |   |                    |     | nrolled/enrolling |
|   |         |   |   | Note = If blank,   |     | in FEHB.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (9) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 0 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member (9) |
|   | CODE_9  | , |   | F = female         |     | who is            |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (9) is used, this |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 1 | AMILY\_ | e | ( | or 5               | ndi | (9) is used, this |
|   |         | x | 1 |                    | tio | field is          |
|   | RELATIO | t | ) | 1 = Spouse         | nal | required.         |
|   | NSHIP_9 | , |   |                    |     |                   |
|   |         | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEH     | T | X | Value = Family     | Op  | This is the SSN   |
| 2 | B_FAMIL | e | ( | member's SSN       | tio | of the enrollee's |
|   | Y_SSN_9 | x | 9 |                    | nal | family member (9) |
|   |         | t | ) | Format = Left      |     | who is            |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (9) is used, this |
|   |         |   |   |                    |     | field is helpful, |
|   |         |   |   |                    |     | but not required. |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEHB_F  | T | X | Value = Family     | Co  | This is the last  |
| 3 | AMILY\_ | e | ( | member's last name | ndi | name of the       |
|   |         | x | 2 |                    | tio | enrollee's family |
|   | MEMBER  | t | 5 | Format = Left      | nal | member (10) who   |
|   | _LAST\_ | , | ) | justify, no        |     | is                |
|   |         | 2 |   | punctuation, pad   |     | e                 |
|   | NAME_10 | 5 |   | with trailing      |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     | This is the       |
|   |         |   |   | pad with spaces    |     | surname of the    |
|   |         |   |   |                    |     | enrollee's family |
|   |         |   |   |                    |     | member (10). The  |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | must always have  |
|   |         |   |   |                    |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a family       |
|   |         |   |   |                    |     | member having     |
|   |         |   |   |                    |     | only one name     |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | family member has |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEHB_F  | T | X | Value = Family     | Co  | This is the first |
| 4 | AMILY\_ | e | ( | member's first     | ndi | name of the       |
|   |         | x | 1 | name               | tio | enrollee's family |
|   | MEMBER_ | t | 7 |                    | nal | member (10) who   |
|   | FIRST\_ | , | ) | Format = Left      |     | is                |
|   |         | 1 |   | justify, no        |     | e                 |
|   | NAME_10 | 7 |   | punctuation, pad   |     | nrolled/enrolling |
|   |         |   |   | with trailing      |     | in FEHB.          |
|   |         |   |   | spaces             |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   | Note = If blank,   |     | (10) is used, and |
|   |         |   |   | pad with spaces    |     | the family member |
|   |         |   |   |                    |     | has a first name, |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required except   |
|   |         |   |   |                    |     | in the rare       |
|   |         |   |   |                    |     | circumstance that |
|   |         |   |   |                    |     | an individual     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEHB_F  | T | X | Value = Family     | Co  | This is the       |
| 5 | AMILY\_ | e | ( | member's middle    | ndi | middle initial of |
|   |         | x | 1 | initial            | tio | the enrollee's    |
|   | M       | t | ) |                    | nal | family member     |
|   | EMBER_M | , |   | Format = No        |     | (10) who is       |
|   | IDDLE\_ | 1 |   | punctuation        |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   | INI     |   |   | Note = If blank,   |     | in FEHB.          |
|   | TIAL_10 |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (10) is used, and |
|   |         |   |   |                    |     | the family member |
|   |         |   |   |                    |     | has a middle name |
|   |         |   |   |                    |     | or initial, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if family member  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEHB_   | T | X | Value = Domestic:  | Op  | This is the       |
| 6 | FAMILY_ | e | ( | 5 digit            | tio | domestic ZIP code |
|   | HOME_ZI | x | 1 | mandatory + 4      | nal | or foreign postal |
|   | P_OR_FO | t | 1 | optional Foreign:  |     | code of the       |
|   | REIGN\_ | , | ) | Postal Code        |     | enrollee's family |
|   |         | 1 |   |                    |     | member (10) who   |
|   | POSTAL_ | 1 |   | Examples:          |     | is                |
|   | CODE_10 |   |   | Domestic: 31206 or |     | e                 |
|   |         |   |   | 312064204;         |     | nrolled/enrolling |
|   |         |   |   | Foreign: H2W 1J5.  |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Format = Left      |     | If family member  |
|   |         |   |   | justify, no        |     | (10) is used,     |
|   |         |   |   | dashes, pad with   |     | this field is     |
|   |         |   |   | trailing spaces    |     | helpful, but not  |
|   |         |   |   |                    |     | required.         |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEHB_F  | T | X | Value = Date of    | Co  | This is the date  |
| 7 | AMILY\_ | e | ( | family member's    | ndi | of birth of the   |
|   |         | x | 8 | birth              | tio | enrollee's family |
|   | DOB_10  | t | ) |                    | nal | member (10) who   |
|   |         | , |   | Format: = YYYYMMDD |     | is                |
|   |         | 8 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (10) is used,     |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEH     | T | X | Value = M or F     | Co  | This code         |
| 8 | B_FAMIL | e | ( |                    | ndi | indicates the sex |
|   | Y_SEX\_ | x | 1 | M = male           | tio | of the enrollee's |
|   |         | t | ) |                    | nal | family member     |
|   | CODE_10 | , |   | F = female         |     | (10) who is       |
|   |         | 1 |   |                    |     | e                 |
|   |         |   |   | Note = If blank,   |     | nrolled/enrolling |
|   |         |   |   | pad with spaces    |     | in FEHB.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (10) is used,     |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 9 | FEHB_F  | T | X | Value = 1,2,3, 4,  | Co  | If family member  |
| 9 | AMILY\_ | e | ( | or 5               | ndi | (10) is used,     |
|   |         | x | 1 |                    | tio | this field is     |
|   | R       | t | ) | 1 = Spouse         | nal | required.         |
|   | ELATION | , |   |                    |     |                   |
|   | SHIP_10 | 1 |   | 2 = Unmarried      |     |                   |
|   |         |   |   | dependent child    |     |                   |
|   |         |   |   | under age 22       |     |                   |
|   |         |   |   | including an       |     |                   |
|   |         |   |   | adopted child      |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 3 = Step child,    |     |                   |
|   |         |   |   | foster child, or   |     |                   |
|   |         |   |   | recognized natural |     |                   |
|   |         |   |   | child              |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 4 = Unmarried      |     |                   |
|   |         |   |   | disabled child     |     |                   |
|   |         |   |   | over age 22        |     |                   |
|   |         |   |   | incapable of       |     |                   |
|   |         |   |   | self-support. If 4 |     |                   |
|   |         |   |   | is used, then      |     |                   |
|   |         |   |   | follow existing    |     |                   |
|   |         |   |   | FEHB Guidelines to |     |                   |
|   |         |   |   | ensure that the    |     |                   |
|   |         |   |   | proper             |     |                   |
|   |         |   |   | documentation is   |     |                   |
|   |         |   |   | provided by the    |     |                   |
|   |         |   |   | agency to the      |     |                   |
|   |         |   |   | carrier.           |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | 5 = Parent of      |     |                   |
|   |         |   |   | dependent          |     |                   |
|   |         |   |   | survivor/annuitant |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FEHB_F  | T | X | Value = Family     | Op  | This is the SSN   |
| 0 | AMILY\_ | e | ( | member's SSN       | tio | of the enrollee's |
| 0 |         | x | 9 |                    | nal | family member     |
|   | SSN_10  | t | ) | Format = Left      |     | (10) who is       |
|   |         | , |   | justify, no        |     | e                 |
|   |         | 9 |   | dashes, pad with   |     | nrolled/enrolling |
|   |         |   |   | spaces             |     | in FEHB. If the   |
|   |         |   |   |                    |     | family member     |
|   |         |   |   | Example: 123456789 |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   | Note = If blank,   |     | provided to the   |
|   |         |   |   | pad with spaces    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If family member  |
|   |         |   |   |                    |     | (10) is used,     |
|   |         |   |   |                    |     | this field is     |
|   |         |   |   |                    |     | helpful, but not  |
|   |         |   |   |                    |     | required.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FEHB_   | T | X | Value = Y or N     | Re  | This code         |
| 0 | OTHER\_ | e | ( |                    | qui | indicates if the  |
| 1 |         | x | 1 | Y = yes            | red | enrollee is       |
|   | INSU    | t | ) |                    |     | enrolled in       |
|   | RANCE\_ | , |   | N = no             |     | another group     |
|   |         | 1 |   |                    |     | health insurance  |
|   | IN      |   |   |                    |     | program.          |
|   | DICATOR |   |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FEHB_   | T | X | Value =            | Co  | This is the       |
| 0 | OTHER\_ | e | ( | Policyholder's     | ndi | surname of the    |
| 2 |         | x | 2 | last name          | tio | individual who    |
|   | INSU    | t | 5 |                    | nal | holds the policy  |
|   | RANCE\_ | , | ) | Format = Left      |     | from another      |
|   |         | 2 |   | justify, no        |     | group health      |
|   | POLICYH | 5 |   | punctuation, pad   |     | insurance program |
|   | OLDER\_ |   |   | with trailing      |     | in which the      |
|   |         |   |   | spaces             |     | enrollee or       |
|   | LA      |   |   |                    |     | family member is  |
|   | ST_NAME |   |   | Note = If blank,   |     | covered. The      |
|   |         |   |   | pad with spaces    |     | policyholder must |
|   |         |   |   |                    |     | always have a     |
|   |         |   |   |                    |     | last name. If     |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of a policyholder |
|   |         |   |   |                    |     | having only one   |
|   |         |   |   |                    |     | name (e.g.,       |
|   |         |   |   |                    |     | Cher), then that  |
|   |         |   |   |                    |     | one name must be  |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | policyholder has  |
|   |         |   |   |                    |     | a title (e.g.,    |
|   |         |   |   |                    |     | Jr, Sr, I, II,    |
|   |         |   |   |                    |     | III), it should   |
|   |         |   |   |                    |     | be entered after  |
|   |         |   |   |                    |     | the last name     |
|   |         |   |   |                    |     | without           |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | This field is     |
|   |         |   |   |                    |     | required if       |
|   |         |   |   |                    |     | FEHB_OTHER\_      |
|   |         |   |   |                    |     | IN                |
|   |         |   |   |                    |     | SURANCE_INDICATOR |
|   |         |   |   |                    |     | is Y.             |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FEHB_   | T | X | Value =            | Co  | This is the first |
| 0 | OTHER\_ | e | ( | Policyholder's     | ndi | name of the       |
| 3 |         | x | 1 | first name         | tio | individual who    |
|   | INSU    | t | 7 |                    | nal | holds the policy  |
|   | RANCE\_ | , | ) | Format = Left      |     | from another      |
|   |         | 1 |   | justify, no        |     | group health      |
|   | POLICYH | 7 |   | punctuation, pad   |     | insurance program |
|   | OLDER\_ |   |   | with trailing      |     | in which the      |
|   |         |   |   | spaces             |     | enrollee or       |
|   | FIR     |   |   |                    |     | family member is  |
|   | ST_NAME |   |   | Note = If blank,   |     | covered. This     |
|   |         |   |   | pad with spaces    |     | must be provided  |
|   |         |   |   |                    |     | except in the     |
|   |         |   |   |                    |     | rare circumstance |
|   |         |   |   |                    |     | that an           |
|   |         |   |   |                    |     | individual only   |
|   |         |   |   |                    |     | has one name      |
|   |         |   |   |                    |     | (e.g., Cher).     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | This field is     |
|   |         |   |   |                    |     | required if       |
|   |         |   |   |                    |     | FEHB_OTHER\_      |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | IN                |
|   |         |   |   |                    |     | SURANCE_INDICATOR |
|   |         |   |   |                    |     | is Y.             |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FEHB_   | T | X | Value =            | Co  | This is the       |
| 0 | OTHER\_ | e | ( | Policyholder's     | ndi | middle initial of |
| 4 |         | x | 1 | middle initial     | tio | the individual    |
|   | INSU    | t | ) |                    | nal | who holds the     |
|   | RANCE\_ | , |   | Format = No        |     | policy from       |
|   |         | 1 |   | punctuation        |     | another group     |
|   | POLICYH |   |   |                    |     | health insurance  |
|   | OLDER\_ |   |   | Note = If blank,   |     | program in which  |
|   |         |   |   | pad with a space   |     | the enrollee or   |
|   | MIDDLE_ |   |   |                    |     | family member is  |
|   | INITIAL |   |   |                    |     | covered. If the   |
|   |         |   |   |                    |     | policyholder uses |
|   |         |   |   |                    |     | one name, or if   |
|   |         |   |   |                    |     | the policyholder  |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | This field is     |
|   |         |   |   |                    |     | required if       |
|   |         |   |   |                    |     | FEHB_OTHER\_      |
|   |         |   |   |                    |     | IN                |
|   |         |   |   |                    |     | SURANCE_INDICATOR |
|   |         |   |   |                    |     | is Y.             |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | MEDICA  | T | X | Value = Y          | Co  | This code is      |
| 0 | RE_IND. | e | ( |                    | ndi | required if the   |
| 5 |         | x | 1 | Y=yes              | tio | FEHB_OTHER\_      |
|   |         | t | ) |                    | nal | IN                |
|   |         | , |   | Note = If blank,   |     | SURANCE_INDICATOR |
|   |         | 1 |   | pad with a space   |     | is Y, and the     |
|   |         |   |   |                    |     | enrollee or       |
|   |         |   |   |                    |     | family member who |
|   |         |   |   |                    |     | is                |
|   |         |   |   |                    |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   |         |   |   |                    |     | in FEHB is        |
|   |         |   |   |                    |     | covered by        |
|   |         |   |   |                    |     | Medicare.         |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | MEDIC   | T | X | Value = Y          | Co  | This code is      |
| 0 | ARE_A\_ | e | ( |                    | ndi | required if the   |
| 6 |         | x | 1 | Y=yes              | tio | Medicare          |
|   | E       | t | ) |                    | nal | Indicator is Y,   |
|   | NROLLEE | , |   | Note = If blank,   |     | and the enrollee  |
|   |         | 1 |   | pad with a space   |     | or family member  |
|   |         |   |   |                    |     | who is            |
|   |         |   |   |                    |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   |         |   |   |                    |     | in FEHB is        |
|   |         |   |   |                    |     | covered by        |
|   |         |   |   |                    |     | Medicare Part A.  |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | MEDIC   | T | X | Value = Y          | Co  | This code is      |
| 0 | ARE_B\_ | e | ( |                    | ndi | required if the   |
| 7 |         | x | 1 | Y = yes            | tio | Medicare          |
|   | E       | t | ) |                    | nal | Indicator is Y,   |
|   | NROLLEE | , |   | Note = If blank,   |     | and the enrollee  |
|   |         | 1 |   | pad with a space   |     | or family member  |
|   |         |   |   |                    |     | who is            |
|   |         |   |   |                    |     | e                 |
|   |         |   |   |                    |     | nrolled/enrolling |
|   |         |   |   |                    |     | in FEHB is        |
|   |         |   |   |                    |     | covered by        |
|   |         |   |   |                    |     | Medicare          |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | Part B.           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | MEDIC   | T | X | Value = Y          | Co  | This code is      |
| 0 | ARE_A\_ | e | ( |                    | ndi | required if the   |
| 8 |         | x | 1 | Y = yes            | tio | Medicare          |
|   | SPOUSE  | t | ) |                    | nal | Indicator is Y,   |
|   |         | , |   | Note = If blank,   |     | and the           |
|   |         | 1 |   | pad with a space   |     | enrollee's spouse |
|   |         |   |   |                    |     | is covered by     |
|   |         |   |   |                    |     | Medicare Part A.  |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | MEDIC   | T | X | Value = Y          | Co  | This code is      |
| 0 | ARE_B\_ | e | ( |                    | ndi | required if the   |
| 9 |         | x | 1 | Y = yes            | tio | Medicare          |
|   | SPOUSE  | t | ) |                    | nal | Indicator is Y,   |
|   |         | , |   | Note = If blank,   |     | and the           |
|   |         | 1 |   | pad with a space   |     | enrollee's spouse |
|   |         |   |   |                    |     | is covered by     |
|   |         |   |   |                    |     | Medicare Part B.  |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | TRIC    | T | X | Value = Y          | Co  | This code is      |
| 1 | ARE_IND | e | ( |                    | ndi | required if       |
| 0 |         | x | 1 | Y = yes            | tio | FEHB_OTHER\_      |
|   |         | t | ) |                    | nal |                   |
|   |         | , |   | Note = If blank,   |     | IN                |
|   |         | 1 |   | pad with a space   |     | SURANCE_INDICATOR |
|   |         |   |   |                    |     | is Y and the      |
|   |         |   |   |                    |     | enrollee is       |
|   |         |   |   |                    |     | covered by        |
|   |         |   |   |                    |     | Tricare or the    |
|   |         |   |   |                    |     | Civilian Health   |
|   |         |   |   |                    |     | and Medical       |
|   |         |   |   |                    |     | Program of the    |
|   |         |   |   |                    |     | Uniformed         |
|   |         |   |   |                    |     | Services          |
|   |         |   |   |                    |     | (CHAMPUS).        |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | O       | T | X | Value = Y          | Co  | This code is      |
| 1 | THER_IN | e | ( |                    | ndi | required if       |
| 1 | SURANCE | x | 1 | Y = yes            | tio | FEHB_OTHER\_      |
|   |         | t | ) |                    | nal | IN                |
|   |         | , |   | Note = If blank,   |     | SURANCE_INDICATOR |
|   |         | 1 |   | pad with a space   |     | is Y, and the     |
|   |         |   |   |                    |     | enrollee is       |
|   |         |   |   |                    |     | covered by a      |
|   |         |   |   |                    |     | group health      |
|   |         |   |   |                    |     | insurance program |
|   |         |   |   |                    |     | other than        |
|   |         |   |   |                    |     | Medicare and      |
|   |         |   |   |                    |     | Tricare           |
|   |         |   |   |                    |     | (including        |
|   |         |   |   |                    |     | CHAMPUS).         |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | OTHER_  | T | X | Value = Name of    | Co  | The name of the   |
| 1 | INSURAN | e | ( | any non-FEHB group | ndi | group health      |
| 2 | CE_NAME | x | 3 | health insurance   | tio | insurance program |
|   |         | t | 5 | program in which   | nal | the enrollee has  |
|   |         | , | ) | the enrollee is    |     | outside of FEHB,  |
|   |         | 3 |   | enrolled.          |     | is required if    |
|   |         | 5 |   |                    |     | FEHB_OTHER_IN     |
|   |         |   |   | Note = If blank,   |     | SURANCE_INDICATOR |
|   |         |   |   | pad with spaces    |     | is Y.             |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PRESENT | T | X | Value = Name of    | Co  | This is the name  |
| 1 | _PLAN\_ | e | ( | the FEHB health    | ndi | of the FEHB       |
| 3 |         | x | 3 | insurance plan     | tio | health insurance  |
|   | NAME    | t | 5 |                    | nal | plan in which the |
|   |         | , | ) | Format = Left      |     | enrollee is       |
|   |         | 3 |   | justify, no        |     | currently         |
|   |         | 5 |   | punctuation, pad   |     | enrolled.         |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     | If                |
|   |         |   |   |                    |     | NATU              |
|   |         |   |   | Note = If blank,   |     | RE_OF_TRANSACTION |
|   |         |   |   | pad with spaces    |     | is CHANGE, this   |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If it   |
|   |         |   |   |                    |     | is START, STOP,   |
|   |         |   |   |                    |     | or SUSPEND, this  |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FILLER  | T | X | Value = Pad with   | Re  | Reserved for      |
| 1 |         | e | ( | spaces             | qui | future use.       |
| 4 |         | x | 7 |                    | red |                   |
|   |         | t | ) |                    |     |                   |
|   |         | , |   |                    |     |                   |
|   |         | 7 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PR      | T | X | Value = Positions  | Co  | This code defines |
| 1 | ESENT\_ | e | ( | 1 and 2 equal the  | ndi | the plan and      |
| 5 |         | x | 3 | plan; 3^rd^        | tio | option of the     |
|   | E       | t | ) | position is plan   | nal | enrollee.         |
|   | NROLLME | , |   | option.            |     |                   |
|   | NT_CODE | 3 |   |                    |     | If                |
|   |         |   |   | Note = If blank,   |     | NATU              |
|   |         |   |   | pad with spaces    |     | RE_OF_TRANSACTION |
|   |         |   |   |                    |     | is CHANGE, STOP,  |
|   |         |   |   |                    |     | or SUSPEND, this  |
|   |         |   |   |                    |     | field is          |
|   |         |   |   |                    |     | required. If it   |
|   |         |   |   |                    |     | is START, this    |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | EVE     | T | X | Value = Blank, 1B, | Co  | The FEHB Event    |
| 1 | NT_CODE | e | ( | 2A, 1C, etc.       | ndi | Code corresponds  |
| 6 |         | x | 2 | depending on the   | tio | to the event that |
|   |         | t | ) | time of year and   | nal | initiated the     |
|   |         | , |   | type of action     |     | enrollee's        |
|   |         | 2 |   |                    |     | action.           |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     | This field is     |
|   |         |   |   |                    |     | required if       |
|   |         |   |   |                    |     | NATURE_OF\_       |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | TRANSACTION is    |
|   |         |   |   |                    |     | START or CHANGE.  |
|   |         |   |   |                    |     | If it is STOP or  |
|   |         |   |   |                    |     | SUSPEND, this     |
|   |         |   |   |                    |     | field is blank.   |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | Refer to SF-2809  |
|   |         |   |   |                    |     | or OPM-2809 for a |
|   |         |   |   |                    |     | list of Event     |
|   |         |   |   |                    |     | Codes.            |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DATE_O  | T | X | Value = The date   | Co  | This is the date  |
| 1 | F_EVENT | e | ( | of the event.      | ndi | of the event that |
| 7 |         | x | 8 |                    | tio | initiated the     |
|   |         | t | ) | Format = YYYYMMDD  | nal | enrollee's        |
|   |         | , |   |                    |     | action.           |
|   |         | 8 |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     | This field is     |
|   |         |   |   |                    |     | required if the   |
|   |         |   |   |                    |     | EVENT_CODE is     |
|   |         |   |   |                    |     | completed.        |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | COVERA  | T | X | Value = Y          | Co  | This code is      |
| 1 | GE_AS\_ | e | ( |                    | ndi | required if       |
| 8 |         | x | 1 | Y = yes            | tio | NATURE_OF\_       |
|   | F       | t | ) |                    | nal |                   |
|   | AMILY_M | , |   | Note = If blank,   |     | TRANSACTION is    |
|   | EMBER\_ | 1 |   | pad with a space   |     | SUSPEND, and the  |
|   |         |   |   |                    |     | enrollee is       |
|   | IN      |   |   |                    |     | suspending        |
|   | DICATOR |   |   |                    |     | his/her FEHB      |
|   |         |   |   |                    |     | enrollment        |
|   |         |   |   |                    |     | because he/she is |
|   |         |   |   |                    |     | going to be       |
|   |         |   |   |                    |     | covered as a      |
|   |         |   |   |                    |     | family member     |
|   |         |   |   |                    |     | under another     |
|   |         |   |   |                    |     | person's FEHB     |
|   |         |   |   |                    |     | enrollment.       |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = Last name  | Co  | This is the       |
| 1 | ON_PROV | e | ( | of the person      | ndi | surname of the    |
| 9 | IDING_F | x | 2 | providing the FEHB | tio | person who is     |
|   | EHB_COV | t | 5 | coverage           | nal | enrolled in FEHB  |
|   | ERAGE\_ | , | ) |                    |     | and whose FEHB    |
|   |         | 2 |   | Format = Left      |     | coverage will     |
|   | LA      | 5 |   | justify, no        |     | cover the family  |
|   | ST_NAME |   |   | punctuation, pad   |     | member after      |
|   |         |   |   | with trailing      |     | he/she suspends   |
|   |         |   |   | spaces             |     | his/her own FEHB  |
|   |         |   |   |                    |     | coverage. If the  |
|   |         |   |   |                    |     | person providing  |
|   |         |   |   |                    |     | the FEHB coverage |
|   |         |   |   |                    |     | has only one name |
|   |         |   |   |                    |     | (e.g., Cher),     |
|   |         |   |   |                    |     | then that one     |
|   |         |   |   |                    |     | name must be      |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | person providing  |
|   |         |   |   |                    |     | the FEHB coverage |
|   |         |   |   |                    |     | has a title       |
|   |         |   |   |                    |     | (e.g., Jr, Sr, I, |
|   |         |   |   |                    |     | II, III), it      |
|   |         |   |   |                    |     | should be entered |
|   |         |   |   |                    |     | after the last    |
|   |         |   |   |                    |     | name without      |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If the            |
|   |         |   |   |                    |     | NATU              |
|   |         |   |   |                    |     | RE_OF_TRANSACTION |
|   |         |   |   |                    |     | code is SUSPEND,  |
|   |         |   |   |                    |     | and the           |
|   |         |   |   |                    |     | COVERAGE_AS\_     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | FAMILY            |
|   |         |   |   |                    |     | _MEMBER_INDICATOR |
|   |         |   |   |                    |     | is Y, this field  |
|   |         |   |   |                    |     | is required.      |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = First name | Co  | This is the first |
| 2 | ON_PROV | e | ( | of the person      | ndi | name of the       |
| 0 | IDING_F | x | 1 | providing the FEHB | tio | person who is     |
|   | EHB_COV | t | 7 | coverage           | nal | enrolled in FEHB  |
|   | ERAGE\_ | , | ) |                    |     | and whose FEHB    |
|   |         | 1 |   | Format = Left      |     | coverage will     |
|   | FIR     | 7 |   | justify, no        |     | cover the family  |
|   | ST_NAME |   |   | punctuation, pad   |     | member after      |
|   |         |   |   | with trailing      |     | he/she suspends   |
|   |         |   |   | spaces             |     | his/her own FEHB  |
|   |         |   |   |                    |     | coverage. This    |
|   |         |   |   | Note = If blank,   |     | must be provided  |
|   |         |   |   | pad with spaces    |     | except in the     |
|   |         |   |   |                    |     | rare circumstance |
|   |         |   |   |                    |     | that the person   |
|   |         |   |   |                    |     | providing the     |
|   |         |   |   |                    |     | FEHB coverage     |
|   |         |   |   |                    |     | only has one name |
|   |         |   |   |                    |     | (e.g., Cher).     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If the            |
|   |         |   |   |                    |     | NATU              |
|   |         |   |   |                    |     | RE_OF_TRANSACTION |
|   |         |   |   |                    |     | code is SUSPEND,  |
|   |         |   |   |                    |     | and the           |
|   |         |   |   |                    |     | COVERAGE_AS\_     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | FAMILY            |
|   |         |   |   |                    |     | _MEMBER_INDICATOR |
|   |         |   |   |                    |     | is Y, this field  |
|   |         |   |   |                    |     | is required.      |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = Middle     | Co  | This is the       |
| 2 | ON_PROV | e | ( | initial of the     | ndi | middle initial of |
| 1 | IDING_F | x | 1 | person providing   | tio | the person who is |
|   | EHB_COV | t | ) | the FEHB coverage  | nal | enrolled in FEHB  |
|   | ERAGE\_ | , |   |                    |     | and whose FEHB    |
|   |         | 1 |   | Format = No        |     | coverage will     |
|   | MIDDLE_ |   |   | punctuation        |     | cover the family  |
|   | INITIAL |   |   |                    |     | member after      |
|   |         |   |   | Note = If blank,   |     | he/she suspends   |
|   |         |   |   | pad with a space   |     | his/her own FEHB  |
|   |         |   |   |                    |     | coverage. If the  |
|   |         |   |   |                    |     | person providing  |
|   |         |   |   |                    |     | the FEHB coverage |
|   |         |   |   |                    |     | uses one name, or |
|   |         |   |   |                    |     | if the person     |
|   |         |   |   |                    |     | providing the     |
|   |         |   |   |                    |     | FEHB coverage     |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If the            |
|   |         |   |   |                    |     | NATU              |
|   |         |   |   |                    |     | RE_OF_TRANSACTION |
|   |         |   |   |                    |     | code is SUSPEND,  |
|   |         |   |   |                    |     | and the           |
|   |         |   |   |                    |     | COVERAGE_AS\_     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | FAMILY            |
|   |         |   |   |                    |     | _MEMBER_INDICATOR |
|   |         |   |   |                    |     | is Y, this field  |
|   |         |   |   |                    |     | is required.      |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = Social     | Co  | This is the SSN   |
| 2 | ON_PROV | e | ( | Security Number    | ndi | or other          |
| 2 | IDING_F | x | 9 | (SSN) or other     | tio | identifying       |
|   | EHB_COV | t | ) | number that is     | nal | number of the     |
|   | ERAGE\_ | , |   | used to identify   |     | person who is     |
|   |         | 9 |   | the person         |     | enrolled in FEHB  |
|   | SOC     |   |   | providing the FEHB |     | and whose FEHB    |
|   | IAL_SEC |   |   | coverage           |     | coverage will     |
|   | URITY\_ |   |   |                    |     | cover the family  |
|   |         |   |   | Format = Left      |     | member after      |
|   | NUMBER  |   |   | justify, no        |     | he/she suspends   |
|   |         |   |   | dashes, pad with   |     | his/her own FEHB  |
|   |         |   |   | trailing spaces    |     | coverage. This    |
|   |         |   |   |                    |     | may be the SSN or |
|   |         |   |   | Example: 123456789 |     | other number such |
|   |         |   |   |                    |     | as the            |
|   |         |   |   | Note = If blank,   |     | OPM-assigned      |
|   |         |   |   | pad with spaces    |     | Civil Service     |
|   |         |   |   |                    |     | Annuitant (CSA)   |
|   |         |   |   |                    |     | number or the     |
|   |         |   |   |                    |     | Civil Service     |
|   |         |   |   |                    |     | Final (CSF)       |
|   |         |   |   |                    |     | number that is    |
|   |         |   |   |                    |     | used to identify  |
|   |         |   |   |                    |     | the person        |
|   |         |   |   |                    |     | providing the     |
|   |         |   |   |                    |     | FEHB coverage. If |
|   |         |   |   |                    |     | the person        |
|   |         |   |   |                    |     | providing the     |
|   |         |   |   |                    |     | FEHB coverage     |
|   |         |   |   |                    |     | does not want     |
|   |         |   |   |                    |     | his/her SSN       |
|   |         |   |   |                    |     | provided to the   |
|   |         |   |   |                    |     | carrier, a pseudo |
|   |         |   |   |                    |     | SSN may be used.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | If the            |
|   |         |   |   |                    |     | NATU              |
|   |         |   |   |                    |     | RE_OF_TRANSACTION |
|   |         |   |   |                    |     | code is SUSPEND,  |
|   |         |   |   |                    |     | and the           |
|   |         |   |   |                    |     | COVERAGE_AS\_     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | FAMILY            |
|   |         |   |   |                    |     | _MEMBER_INDICATOR |
|   |         |   |   |                    |     | is Y, this field  |
|   |         |   |   |                    |     | is required.      |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | MMCP\_  | T | X | Value = Y          | Co  | This code is      |
| 2 |         | e | ( |                    | ndi | required if the   |
| 3 | ENROL   | x | 1 | Y = yes            | tio | NATURE_OF\_       |
|   | LMENT\_ | t | ) |                    | nal |                   |
|   |         | , |   | Note = If blank,   |     | TRANSACTION code  |
|   | IN      | 1 |   | pad with a space   |     | is SUSPEND, and   |
|   | DICATOR |   |   |                    |     | the enrollee is   |
|   |         |   |   |                    |     | suspending        |
|   |         |   |   |                    |     | his/her FEHB      |
|   |         |   |   |                    |     | enrollment        |
|   |         |   |   |                    |     | because he/she    |
|   |         |   |   |                    |     | enrolled in MMCP. |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | CANCELL | T | X | Value = Y          | Co  | This code is      |
| 2 | ATION\_ | e | ( |                    | ndi | required if the   |
| 4 |         | x | 1 | Y = yes            | tio | NATURE_OF\_       |
|   | IN      | t | ) |                    | nal |                   |
|   | DICATOR | , |   | Note = If blank,   |     | TRANSACTION is    |
|   |         | 1 |   | pad with a space   |     | STOP, and the     |
|   |         |   |   |                    |     | enrollee is       |
|   |         |   |   |                    |     | canceling his/her |
|   |         |   |   |                    |     | FEHB enrollment.  |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | COV     | T | X | Value = The date   | Re  | This is the       |
| 2 | ERAGE\_ | e | ( | the requested      | qui | effective date of |
| 5 |         | x | 8 | action goes into   | red | the requested     |
|   | EFFECTI | t | ) | effect.            |     | action.           |
|   | VE_DATE | , |   |                    |     |                   |
|   |         | 8 |   | Format: YYYYMMDD   |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DATE_OF | T | X | Value = The date   | Re  | This is the date  |
| 2 | _ACTION | e | ( | the enrollee made  | qui | the enrollee made |
| 6 |         | x | 8 | this election      | red | this election.    |
|   |         | t | ) |                    |     |                   |
|   |         | , |   | Format = YYYYMMDD  |     |                   |
|   |         | 8 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | TIME_OF | T | X | Value = The time   | Re  | This is the time  |
| 2 | _ACTION | e | ( | the corrective     | qui | the corrective    |
| 7 |         | x | 6 | action record was  | red | action record was |
|   |         | t | ) | completed.         |     | completed.        |
|   |         | , |   |                    |     |                   |
|   |         | 6 |   | Format = HHMMSS,   |     | This time will be |
|   |         |   |   | 24 hours military  |     | system generated. |
|   |         |   |   | time               |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Example: 162206    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AG      | T | X | Value = 4-position | Co  | Required if       |
| 2 | ENCY_ID | e | ( | agency identifier  | ndi | available.        |
| 8 |         | x | 4 |                    | tio |                   |
|   |         | t | ) | Note = If blank,   | nal | The agency and,   |
|   |         | , |   | pad with spaces    |     | where applicable, |
|   |         | 4 |   |                    |     | the               |
|   |         |   |   |                    |     | administrative    |
|   |         |   |   |                    |     | subdivision       |
|   |         |   |   |                    |     | (i.e.,            |
|   |         |   |   |                    |     | subelement) in    |
|   |         |   |   |                    |     | which a person is |
|   |         |   |   |                    |     | employed. The     |
|   |         |   |   |                    |     | first and second  |
|   |         |   |   |                    |     | positions of the  |
|   |         |   |   |                    |     | code indicate the |
|   |         |   |   |                    |     | agency. The third |
|   |         |   |   |                    |     | and fourth        |
|   |         |   |   |                    |     | positions         |
|   |         |   |   |                    |     | indicate the      |
|   |         |   |   |                    |     | administrative    |
|   |         |   |   |                    |     | subdivision       |
|   |         |   |   |                    |     | (i.e.,            |
|   |         |   |   |                    |     | subelement). If   |
|   |         |   |   |                    |     | no subelements    |
|   |         |   |   |                    |     | are assigned to   |
|   |         |   |   |                    |     | an agency, the    |
|   |         |   |   |                    |     | third and fourth  |
|   |         |   |   |                    |     | positions are     |
|   |         |   |   |                    |     | zeros (xx00).     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | To find out more  |
|   |         |   |   |                    |     | about this field, |
|   |         |   |   |                    |     | go to the         |
|   |         |   |   |                    |     | following         |
|   |         |   |   |                    |     | Internet address: |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | <http:/           |
|   |         |   |   |                    |     | /www.opm.gov/fedd |
|   |         |   |   |                    |     | ata/guidance.htm> |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | For example,      |
|   |         |   |   |                    |     | NFC's Payroll     |
|   |         |   |   |                    |     | Personnel System  |
|   |         |   |   |                    |     | is payroll office |
|   |         |   |   |                    |     | number 12400001,  |
|   |         |   |   |                    |     | but its agency    |
|   |         |   |   |                    |     | code is AG90.     |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | This is required  |
|   |         |   |   |                    |     | for all enrollees |
|   |         |   |   |                    |     | who are currently |
|   |         |   |   |                    |     | on an agency's    |
|   |         |   |   |                    |     | rolls. Retirees   |
|   |         |   |   |                    |     | and former        |
|   |         |   |   |                    |     | employees who     |
|   |         |   |   |                    |     | maintain coverage |
|   |         |   |   |                    |     | are **not         |
|   |         |   |   |                    |     | required** to     |
|   |         |   |   |                    |     | have Agency and   |
|   |         |   |   |                    |     | POI, and in those |
|   |         |   |   |                    |     | cases, pad this   |
|   |         |   |   |                    |     | field with        |
|   |         |   |   |                    |     | spaces.           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERSO   | T | X | Value = 4-position | Co  | Required if       |
| 2 | NNEL_OF | e | ( | Personnel Office   | ndi | available.        |
| 9 | FICE_ID | x | 4 | identifier         | tio |                   |
|   |         | t | ) |                    | nal | The               |
|   |         | , |   |                    |     | identification of |
|   |         | 4 |   |                    |     | the Federal       |
|   |         |   |   |                    |     | civilian          |
|   |         |   |   |                    |     | personnel office  |
|   |         |   |   |                    |     | authorized to     |
|   |         |   |   |                    |     | appoint and       |
|   |         |   |   |                    |     | separate an       |
|   |         |   |   |                    |     | employee, and to  |
|   |         |   |   |                    |     | the extent such   |
|   |         |   |   |                    |     | functions have    |
|   |         |   |   |                    |     | been delegated,   |
|   |         |   |   |                    |     | prepare personnel |
|   |         |   |   |                    |     | actions, maintain |
|   |         |   |   |                    |     | official          |
|   |         |   |   |                    |     | personnel         |
|   |         |   |   |                    |     | records, and      |
|   |         |   |   |                    |     | administer        |
|   |         |   |   |                    |     | programs for all  |
|   |         |   |   |                    |     | staff             |
|   |         |   |   |                    |     | compensation,     |
|   |         |   |   |                    |     | training and      |
|   |         |   |   |                    |     | development,      |
|   |         |   |   |                    |     | benefits and      |
|   |         |   |   |                    |     | awards, and       |
|   |         |   |   |                    |     | employee and      |
|   |         |   |   |                    |     | labor relations.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | The personnel     |
|   |         |   |   |                    |     | office names and  |
|   |         |   |   |                    |     | codes can be      |
|   |         |   |   |                    |     | found in the      |
|   |         |   |   |                    |     | Personnel Office  |
|   |         |   |   |                    |     | Identifier (POI)  |
|   |         |   |   |                    |     | Listing (produced |
|   |         |   |   |                    |     | by the Office of  |
|   |         |   |   |                    |     | Workforce         |
|   |         |   |   |                    |     | Information,      |
|   |         |   |   |                    |     | Office of         |
|   |         |   |   |                    |     | Personnel         |
|   |         |   |   |                    |     | Management). The  |
|   |         |   |   |                    |     | Listing contains  |
|   |         |   |   |                    |     | the               |
|   |         |   |   |                    |     | agency/subelement |
|   |         |   |   |                    |     | code, the         |
|   |         |   |   |                    |     | personnel office  |
|   |         |   |   |                    |     | code, the name    |
|   |         |   |   |                    |     | and mailing       |
|   |         |   |   |                    |     | address of the    |
|   |         |   |   |                    |     | personnel office, |
|   |         |   |   |                    |     | and the name,     |
|   |         |   |   |                    |     | title and         |
|   |         |   |   |                    |     | telephone number  |
|   |         |   |   |                    |     | of the personnel  |
|   |         |   |   |                    |     | office contact.   |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | To find out more  |
|   |         |   |   |                    |     | about this field, |
|   |         |   |   |                    |     | go to the         |
|   |         |   |   |                    |     | following         |
|   |         |   |   |                    |     | Internet address: |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | [h                |
|   |         |   |   |                    |     | ttp://www.opm.gov |
|   |         |   |   |                    |     | /feddata/guidance |
|   |         |   |   |                    |     | .htm](http://www. |
|   |         |   |   |                    |     | opm.gov/feddata/h |
|   |         |   |   |                    |     | tml/datastan.htm) |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | For example, the  |
|   |         |   |   |                    |     | NFC is AG90, POI  |
|   |         |   |   |                    |     | 5317. This was    |
|   |         |   |   |                    |     | formerly known as |
|   |         |   |   |                    |     | the submitting    |
|   |         |   |   |                    |     | office number.    |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | This is required  |
|   |         |   |   |                    |     | for all enrollees |
|   |         |   |   |                    |     | who are currently |
|   |         |   |   |                    |     | on an agency's    |
|   |         |   |   |                    |     | rolls. Retirees   |
|   |         |   |   |                    |     | and former        |
|   |         |   |   |                    |     | employees who     |
|   |         |   |   |                    |     | maintain coverage |
|   |         |   |   |                    |     | are **not         |
|   |         |   |   |                    |     | required** to     |
|   |         |   |   |                    |     | have Agency and   |
|   |         |   |   |                    |     | POI, and in those |
|   |         |   |   |                    |     | cases, pad this   |
|   |         |   |   |                    |     | field with        |
|   |         |   |   |                    |     | spaces.           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PAY     | T | X | Value = Payroll    | Re  | This number is    |
| 3 | ROLL_OF | e | ( | Office             | qui | assigned by       |
| 0 | FICE_ID | x | 8 | Identification     | red | Treasury and OPM  |
|   |         | t | ) |                    |     | to the            |
|   |         | , |   | Format = Left      |     | organization that |
|   |         | 8 |   | justify, pad with  |     | is responsible    |
|   |         |   |   | trailing spaces    |     | for coordinating  |
|   |         |   |   |                    |     | the enrollee's    |
|   |         |   |   |                    |     | FEHB coverage and |
|   |         |   |   |                    |     | premium           |
|   |         |   |   |                    |     | collection.       |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | CLAIM   | T | X | Value = Valid      | Co  | The Claim Number  |
| 3 | _NUMBER | e | ( | Claim Number       | ndi | is the number     |
| 1 |         | x | 9 |                    | tio | assigned by OPM,  |
|   |         | t | ) | Note = If blank,   | nal | other retirement  |
|   |         | , |   | pad with spaces    |     | systems, or the   |
|   |         | 9 |   |                    |     | Office of         |
|   |         |   |   | Example:           |     | Workers'          |
|   |         |   |   | CSA123456789,      |     | Compensation      |
|   |         |   |   | CSF123456789       |     | Program (i.e.,    |
|   |         |   |   |                    |     | CSA, CSF, or      |
|   |         |   |   |                    |     | compensation      |
|   |         |   |   |                    |     | number). This     |
|   |         |   |   |                    |     | number should be  |
|   |         |   |   |                    |     | provided, if      |
|   |         |   |   |                    |     | applicable.       |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | ANNUITA | T | X | Value = SSN of the | Co  | This field        |
| 3 | NT_OR\_ | e | ( | original annuitant | ndi | contains the SSN  |
| 2 |         | x | 9 | enrolled in this   | tio | of the retiree or |
|   | SURVIVO | t | ) | FEHB plan          | nal | in the case of a  |
|   | R_SSN\_ | , |   |                    |     | survivor          |
|   |         | 9 |   | Note = If blank,   |     | annuitant, the    |
|   | (HB_I   |   |   | pad with spaces    |     | SSN of the        |
|   | DENTIFI |   |   |                    |     | deceased          |
|   | CATION_ |   |   |                    |     | retiree/employee. |
|   | NUMBER) |   |   |                    |     | The HB            |
|   |         |   |   |                    |     | Identification    |
|   |         |   |   |                    |     | Number is the SSN |
|   |         |   |   |                    |     | of the person to  |
|   |         |   |   |                    |     | whom the policy   |
|   |         |   |   |                    |     | was originally    |
|   |         |   |   |                    |     | issued and it     |
|   |         |   |   |                    |     | will not change.  |
|   |         |   |   |                    |     | The SSN field can |
|   |         |   |   |                    |     | and does change   |
|   |         |   |   |                    |     | at the death of   |
|   |         |   |   |                    |     | the annuitant,    |
|   |         |   |   |                    |     | but the HB        |
|   |         |   |   |                    |     | Identification    |
|   |         |   |   |                    |     | Number does not.  |
|   |         |   |   |                    |     |                   |
|   |         |   |   |                    |     | This field is     |
|   |         |   |   |                    |     | required for      |
|   |         |   |   |                    |     | annuitants only.  |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FILLER  | T | X | Value = Pad with   | Re  | Reserved for      |
| 3 |         | e | ( | spaces             | qui | future use.       |
| 3 |         | x | 2 |                    | red |                   |
|   |         | t | ) |                    |     |                   |
|   |         | , |   |                    |     |                   |
|   |         | 2 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | REPORT  | T | X | Value = System     | Re  | The first 8       |
| 3 | _NUMBER | e | ( | generated number   | qui | positions of this |
| 4 |         | x | 1 |                    | red | number are system |
|   |         | t | 5 | Format = Left      |     | generated and     |
|   |         | , | ) | justify, pad with  |     | indicate the      |
|   |         | 1 |   | trailing spaces    |     | quarter and year  |
|   |         | 5 |   |                    |     | in which a record |
|   |         |   |   | Example:           |     | was transmitted   |
|   |         |   |   | NFC22002XXXXXXX =  |     | plus the optional |
|   |         |   |   |                    |     | 7-digit control   |
|   |         |   |   | second quarter in  |     | number. The user  |
|   |         |   |   | the year 2002      |     | has the option of |
|   |         |   |   |                    |     | entering the      |
|   |         |   |   |                    |     | number of his/her |
|   |         |   |   |                    |     | original report   |
|   |         |   |   |                    |     | (notification to  |
|   |         |   |   |                    |     | carrier, SF-2811, |
|   |         |   |   |                    |     | etc.) in the      |
|   |         |   |   |                    |     | remaining 7       |
|   |         |   |   |                    |     | spaces.           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AGEN    | T | X | Value = The name   | Re  | This is the name  |
| 3 | CY_NAME | e | ( | of the enrollee's  | qui | of the employing, |
| 5 |         | x | 3 | employing,         | red | personnel, or     |
|   |         | t | 5 | personnel, or      |     | point of contact  |
|   |         | , | ) | point of contact   |     | office that is    |
|   |         | 3 |   | office             |     | responsible for   |
|   |         | 5 |   |                    |     | coordinating the  |
|   |         |   |   | Format = Left      |     | enrollee's FEHB   |
|   |         |   |   | justify, no        |     | coverage.         |
|   |         |   |   | punctuation, pad   |     |                   |
|   |         |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DOMEST  | T | X | Value = The first  | Co  | This is the first |
| 3 | IC_OR\_ | e | ( | line of the        | ndi | line of the       |
| 6 |         | x | 3 | employing,         | tio | domestic or       |
|   | FO      | t | 5 | personnel, or      | nal | foreign street,   |
|   | REIGN\_ | , | ) | point of contact   |     | PO box, rural     |
|   |         | 3 |   | office's domestic  |     | route, etc., of   |
|   | A       | 5 |   | or foreign street  |     | the employing,    |
|   | GENCY_S |   |   | address            |     | personnel, or     |
|   | TREET_1 |   |   |                    |     | point of contact  |
|   |         |   |   | Format = Left      |     | office that is    |
|   |         |   |   | justify, no        |     | responsible for   |
|   |         |   |   | punctuation, pad   |     | coordinating the  |
|   |         |   |   | with trailing      |     | enrollee's FEHB   |
|   |         |   |   | spaces             |     | coverage.         |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Example: Route 1   |     | This field is     |
|   |         |   |   | Box 618B           |     | required except   |
|   |         |   |   |                    |     | in rare cases     |
|   |         |   |   |                    |     | where the address |
|   |         |   |   |                    |     | does not contain  |
|   |         |   |   |                    |     | a street or PO    |
|   |         |   |   |                    |     | box (i.e., John   |
|   |         |   |   |                    |     | Doe, Modale, IA   |
|   |         |   |   |                    |     | 51556).           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DOMEST  | T | X | Value = The second | Co  | This is the       |
| 3 | IC_OR\_ | e | ( | line of the        | ndi | second line of    |
| 7 |         | x | 3 | employing,         | tio | the domestic or   |
|   | FO      | t | 5 | personnel, or      | nal | foreign street,   |
|   | REIGN_A | , | ) | point of contact   |     | PO box, rural     |
|   | GENCY\_ | 3 |   | office's domestic  |     | route, etc., of   |
|   |         | 5 |   | or foreign street  |     | the employing,    |
|   | S       |   |   | address            |     | personnel, or     |
|   | TREET_2 |   |   |                    |     | point of contact  |
|   |         |   |   | Format = Left      |     | office that is    |
|   |         |   |   | justify, no        |     | responsible for   |
|   |         |   |   | punctuation, pad   |     | coordinating the  |
|   |         |   |   | with trailing      |     | enrollee's FEHB   |
|   |         |   |   | spaces             |     | coverage.         |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     | This field is     |
|   |         |   |   | pad with spaces    |     | required except   |
|   |         |   |   |                    |     | in rare cases     |
|   |         |   |   |                    |     | where the address |
|   |         |   |   |                    |     | does not contain  |
|   |         |   |   |                    |     | a street or PO    |
|   |         |   |   |                    |     | box (i.e., John   |
|   |         |   |   |                    |     | Doe, Modale, IA   |
|   |         |   |   |                    |     | 51556).           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DOMEST  | T | X | Value = The third  | Co  | This is the third |
| 3 | IC_OR\_ | e | ( | line of the        | ndi | line of the       |
| 8 |         | x | 3 | employing,         | tio | domestic or       |
|   | FO      | t | 5 | personnel, or      | nal | foreign street,   |
|   | REIGN\_ | , | ) | point of contact   |     | PO box, rural     |
|   |         | 3 |   | office's domestic  |     | route, etc., of   |
|   | A       | 5 |   | or foreign street  |     | the employing,    |
|   | GENCY_S |   |   | address            |     | personnel, or     |
|   | TREET_3 |   |   |                    |     | point of contact  |
|   |         |   |   | Format = Left      |     | office that is    |
|   |         |   |   | justify, no        |     | responsible for   |
|   |         |   |   | punctuation, pad   |     | coordinating the  |
|   |         |   |   | with trailing      |     | enrollee's FEHB   |
|   |         |   |   | spaces             |     | coverage.         |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     | This field is     |
|   |         |   |   | pad with spaces    |     | required except   |
|   |         |   |   |                    |     | in rare cases     |
|   |         |   |   |                    |     | where the address |
|   |         |   |   |                    |     | does not contain  |
|   |         |   |   |                    |     | a street or PO    |
|   |         |   |   |                    |     | box (i.e., John   |
|   |         |   |   |                    |     | Doe, Modale, IA   |
|   |         |   |   |                    |     | 51556).           |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DOMEST  | T | X | Value = Employing, | Re  | This is the       |
| 3 | IC_OR\_ | e | ( | personnel, or      | qui | domestic or       |
| 9 |         | x | 2 | point of contact   | red | foreign city in   |
|   | FO      | t | 3 | office's domestic  |     | which the         |
|   | REIGN\_ | , | ) | or foreign city    |     | enrollee's        |
|   |         | 2 |   | name               |     | employing,        |
|   | AGEN    | 3 |   |                    |     | personnel, or     |
|   | CY_CITY |   |   | Format: = Left     |     | point of contact  |
|   |         |   |   | justify, pad with  |     | office is         |
|   |         |   |   | trailing spaces    |     | located.          |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Example: Macon     |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DOM     | T | X | Value = Employing, | Co  | This is the       |
| 4 | ESTIC\_ | e | ( | personnel, or      | ndi | abbreviation of   |
| 0 |         | x | 2 | point of contact   | tio | the domestic      |
|   | AGENC   | t | ) | office's domestic  | nal | state in which    |
|   | Y_STATE | , |   | state abbreviation |     | the enrollee's    |
|   |         | 2 |   |                    |     | employing,        |
|   |         |   |   | Example: GA for    |     | personnel, or     |
|   |         |   |   | Georgia            |     | point of contact  |
|   |         |   |   |                    |     | office is         |
|   |         |   |   | Note = If blank,   |     | located.          |
|   |         |   |   | pad with spaces    |     |                   |
|   |         |   |   |                    |     | If the address is |
|   |         |   |   |                    |     | foreign, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | FO      | T | X | Value = Employing, | Co  | This is the name  |
| 4 | REIGN\_ | e | ( | personnel, or      | ndi | of the employing, |
| 1 |         | x | 2 | point of contact   | tio | personnel, or     |
|   | AG      | t | 3 | office's foreign   | nal | point of contact  |
|   | ENCY_CO | , | ) | country name       |     | office's foreign  |
|   | UNTRY\_ | 2 |   |                    |     | country.          |
|   |         | 3 |   | Format = Left      |     |                   |
|   | NAME    |   |   | justify, pad with  |     | If the address is |
|   |         |   |   | trailing spaces    |     | domestic, this    |
|   |         |   |   |                    |     | field is blank.   |
|   |         |   |   | Example: Canada    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AGEN    | T | X | Value = Employing, | Re  | This is the       |
| 4 | CY_DOME | e | ( | personnel, or      | qui | domestic ZIP code |
| 2 | STIC_ZI | x | 1 | point of contact   | red | or foreign postal |
|   | P_OR_FO | t | 1 | office's valid     |     | code for the      |
|   | REIGN\_ | , | ) | domestic ZIP Code  |     | employing,        |
|   |         | 1 |   | or foreign postal  |     | personnel, or     |
|   | POST    | 1 |   | code               |     | point of contact  |
|   | AL_CODE |   |   |                    |     | office's address. |
|   |         |   |   | Format = Left      |     |                   |
|   |         |   |   | justify, no        |     |                   |
|   |         |   |   | dashes, pad with   |     |                   |
|   |         |   |   | trailing spaces    |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Examples:          |     |                   |
|   |         |   |   | Domestic: 31206 or |     |                   |
|   |         |   |   | 312064204;         |     |                   |
|   |         |   |   | Foreign: H2W 1J5   |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AG      | T | X | Value = Valid U.S. | Op  | This code         |
| 4 | ENCY_CO | e | ( | Postal Service     | tio | identifies the    |
| 3 | UNTRY\_ | x | 3 | country code       | nal | country for the   |
|   |         | t | ) |                    |     | employing,        |
|   | CODE    | , |   | Note = If blank,   |     | personnel, or     |
|   |         | 3 |   | pad with spaces    |     | point of contact  |
|   |         |   |   |                    |     | office's address. |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | DA      | T | X | Value = Date the   | Re  | This is the date  |
| 4 | TE_RECE | e | ( | employing,         | qui | the employing,    |
| 4 | IVED_IN | x | 8 | personnel, or      | red | personnel, or     |
|   | _AGENCY | t | ) | point of contact   |     | point of contact  |
|   | _OFFICE | , |   | office received    |     | office received   |
|   |         | 8 |   | the 2809.          |     | the 2809.         |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Format =YYYYMMDD   |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AUTHO   | T | X | Value = Agency     | Re  | This is the       |
| 4 | RIZED\_ | e | ( | official's last    | qui | surname of the    |
| 5 |         | x | 2 | name               | red | agency official   |
|   | AGE     | t | 5 |                    |     | who is authorized |
|   | NCY_OFF | , | ) | Format = Left      |     | to sign the 2809. |
|   | ICIAL\_ | 2 |   | justify, no        |     | The authorized    |
|   |         | 5 |   | punctuation, pad   |     | agency official   |
|   | LA      |   |   | with trailing      |     | must always have  |
|   | ST_NAME |   |   | spaces             |     | a last name. If   |
|   |         |   |   |                    |     | there is a case   |
|   |         |   |   |                    |     | of an authorized  |
|   |         |   |   |                    |     | agency official   |
|   |         |   |   |                    |     | having only one   |
|   |         |   |   |                    |     | name (e.g.,       |
|   |         |   |   |                    |     | Cher), then that  |
|   |         |   |   |                    |     | one name must be  |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | authorized agency |
|   |         |   |   |                    |     | official has a    |
|   |         |   |   |                    |     | title (e.g., Jr,  |
|   |         |   |   |                    |     | Sr, I, II, III),  |
|   |         |   |   |                    |     | it should be      |
|   |         |   |   |                    |     | entered after the |
|   |         |   |   |                    |     | last name without |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AUTHO   | T | X | Value = Agency     | Co  | First name of the |
| 4 | RIZED\_ | e | ( | official's first   | ndi | agency official   |
| 6 |         | x | 1 | name               | tio | who is authorized |
|   | AGE     | t | 7 |                    | nal | to sign the 2809. |
|   | NCY_OFF | , | ) | Format = Left      |     | This must be      |
|   | ICIAL\_ | 1 |   | justify, no        |     | provided except   |
|   |         | 7 |   | punctuation, pad   |     | in the rare       |
|   | FIR     |   |   | with trailing      |     | circumstance that |
|   | ST_NAME |   |   | spaces             |     | the agency        |
|   |         |   |   |                    |     | official only has |
|   |         |   |   | Note = If blank,   |     | one name (e.g.,   |
|   |         |   |   | pad with spaces    |     | Cher).            |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AUTHO   | T | X | Value = Agency     | Co  | This is the       |
| 4 | RIZED\_ | e | ( | official's middle  | ndi | middle initial of |
| 7 |         | x | 1 | initial            | tio | the agency        |
|   | AGE     | t | ) |                    | nal | official who is   |
|   | NCY_OFF | , |   | Format = No        |     | authorized to     |
|   | ICIAL\_ | 1 |   | punctuation        |     | sign the 2809. If |
|   |         |   |   |                    |     | the agency        |
|   | MIDDLE_ |   |   | Note = If blank,   |     | official uses one |
|   | INITIAL |   |   | pad with a space   |     | name, or if the   |
|   |         |   |   |                    |     | agency official   |
|   |         |   |   |                    |     | does not have a   |
|   |         |   |   |                    |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AUTHO   | T | X | Value = Agency     | Op  | This is the       |
| 4 | RIZED\_ | e | ( | official's daytime | tio | agency official's |
| 8 |         | x | 1 | area code and      | nal | telephone number. |
|   | AGE     | t | 7 | phone number       |     |                   |
|   | NCY_OFF | , | ) |                    |     |                   |
|   | ICIAL\_ | 1 |   | Format = Left      |     |                   |
|   |         | 7 |   | justify, no dashes |     |                   |
|   | TE      |   |   | or spaces, pad     |     |                   |
|   | LEPHONE |   |   | with trailing      |     |                   |
|   | _NUMBER |   |   | spaces             |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Example:           |     |                   |
|   |         |   |   | 9127442286         |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | AUTHO   | T | X | Value = The date   | Co  | This field is     |
| 4 | RIZED\_ | e | ( | the authorized     | ndi | provided for the  |
| 9 |         | x | 8 | agency official    | tio | Office of         |
|   | AGE     | t | ) | signed the         | nal | Retirement        |
|   | NCY_OFF | , |   | document.          |     | Programs use. It  |
|   | ICIAL\_ | 8 |   |                    |     | may be used by    |
|   |         |   |   | Format = YYYYMMDD  |     | other agencies at |
|   | SIGNATU |   |   |                    |     | their discretion. |
|   | RE_DATE |   |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = Personnel  | Re  | This is the       |
| 5 | ONNEL_O | e | ( | office contact's   | qui | surname of the    |
| 0 | FFICE\_ | x | 2 | last name          | red | personnel office  |
|   |         | t | 5 |                    |     | contact. The      |
|   | CONTACT | , | ) | Format = Left      |     | contact must      |
|   | _LAST\_ | 2 |   | justify, no        |     | always have a     |
|   |         | 5 |   | punctuation, pad   |     | last name. If     |
|   | NAME    |   |   | with trailing      |     | there is a case   |
|   |         |   |   | spaces             |     | of a contact      |
|   |         |   |   |                    |     | having only one   |
|   |         |   |   |                    |     | name (e.g.,       |
|   |         |   |   |                    |     | Cher), then that  |
|   |         |   |   |                    |     | one name must be  |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | contact has a     |
|   |         |   |   |                    |     | title (e.g., Jr,  |
|   |         |   |   |                    |     | Sr, I, II, III),  |
|   |         |   |   |                    |     | it should be      |
|   |         |   |   |                    |     | entered after the |
|   |         |   |   |                    |     | last name without |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = Personnel  | Co  | First name of the |
| 5 | ONNEL_O | e | ( | office contact's   | ndi | personnel office  |
| 1 | FFICE\_ | x | 1 | first name         | tio | contact. This     |
|   |         | t | 7 |                    | nal | must be provided  |
|   | C       | , | ) | Format = Left      |     | except in the     |
|   | ONTACT_ | 1 |   | justify, no        |     | rare circumstance |
|   | FIRST\_ | 7 |   | punctuation, pad   |     | that the contact  |
|   |         |   |   | with trailing      |     | only has one name |
|   | NAME    |   |   | spaces             |     | (e.g., Cher).     |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = Personnel  | Co  | This is the       |
| 5 | ONNEL_O | e | ( | office contact's   | ndi | middle initial of |
| 2 | FFICE\_ | x | 1 | middle initial     | tio | the personnel     |
|   |         | t | ) |                    | nal | office contact.   |
|   | CO      | , |   | Format = No        |     | If the contact    |
|   | NTACT_M | 1 |   | punctuation        |     | uses one name, or |
|   | IDDLE\_ |   |   |                    |     | if the contact    |
|   |         |   |   | Note = If blank,   |     | does not have a   |
|   | INITIAL |   |   | pad with a space   |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PERS    | T | X | Value = Personnel  | Op  | This is the       |
| 5 | ONNEL_O | e | ( | office contact's   | tio | personnel office  |
| 3 | FFICE\_ | x | 1 | daytime area code  | nal | contact's         |
|   |         | t | 7 | and phone number   |     | telephone number. |
|   | CO      | , | ) |                    |     |                   |
|   | NTACT\_ | 1 |   | Format = Left      |     |                   |
|   |         | 7 |   | justify, no dashes |     |                   |
|   | TELE    |   |   | or spaces, pad     |     |                   |
|   | PHONE\_ |   |   | with trailing      |     |                   |
|   |         |   |   | spaces             |     |                   |
|   | NUMBER  |   |   |                    |     |                   |
|   |         |   |   | Example:           |     |                   |
|   |         |   |   | 9127442286         |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PA      | T | X | Value = Payroll    | Re  | This is the       |
| 5 | YROLL_O | e | ( | office contact's   | qui | surname of the    |
| 4 | FFICE\_ | x | 2 | last name          | red | payroll office    |
|   |         | t | 5 |                    |     | contact. The      |
|   | CO      | , | ) | Format = Left      |     | contact must      |
|   | NTACT\_ | 2 |   | justify, no        |     | always have a     |
|   |         | 5 |   | punctuation, pad   |     | last name. If     |
|   | LA      |   |   | with trailing      |     | there is case of  |
|   | ST_NAME |   |   | spaces             |     | the contact       |
|   |         |   |   |                    |     | having only one   |
|   |         |   |   |                    |     | name (e.g.,       |
|   |         |   |   |                    |     | Cher), then that  |
|   |         |   |   |                    |     | one name must be  |
|   |         |   |   |                    |     | placed in this    |
|   |         |   |   |                    |     | field. If the     |
|   |         |   |   |                    |     | contact has a     |
|   |         |   |   |                    |     | title (e.g., Jr,  |
|   |         |   |   |                    |     | Sr, I, II, III),  |
|   |         |   |   |                    |     | it should be      |
|   |         |   |   |                    |     | entered after the |
|   |         |   |   |                    |     | last name without |
|   |         |   |   |                    |     | punctuation. For  |
|   |         |   |   |                    |     | example: Smith Jr |
|   |         |   |   |                    |     | or Smith III.     |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PA      | T | X | Value = Payroll    | Co  | First name of the |
| 5 | YROLL_O | e | ( | office contact's   | ndi | payroll office    |
| 5 | FFICE\_ | x | 1 | first name         | tio | contact. This     |
|   |         | t | 7 |                    | nal | must be provided  |
|   | CO      | , | ) | Format = Left      |     | except in the     |
|   | NTACT\_ | 1 |   | justify, no        |     | rare circumstance |
|   |         | 7 |   | punctuation, pad   |     | that the contact  |
|   | FIR     |   |   | with trailing      |     | only has one name |
|   | ST_NAME |   |   | spaces             |     | (e.g., Cher).     |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PA      | T | X | Value = Payroll    | Co  | This is the       |
| 5 | YROLL_O | e | ( | office contact's   | ndi | middle initial of |
| 6 | FFICE\_ | x | 1 | middle initial     | tio | the payroll       |
|   |         | t | ) |                    | nal | office contact.   |
|   | CO      | , |   | Format = No        |     | If the contact    |
|   | NTACT\_ | 1 |   | punctuation        |     | uses one name, or |
|   |         |   |   |                    |     | if the contact    |
|   | MIDDLE_ |   |   | Note = If blank,   |     | does not have a   |
|   | INITIAL |   |   | pad with a space   |     | middle name or    |
|   |         |   |   |                    |     | initial, this     |
|   |         |   |   |                    |     | field is blank.   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | PA      | T | X | Value = Payroll    | Op  | This is the       |
| 5 | YROLL_O | e | ( | office contact's   | tio | payroll office    |
| 7 | FFICE\_ | x | 1 | daytime area code  | nal | contact's         |
|   |         | t | 7 | and phone number   |     | telephone number. |
|   | CO      | , | ) |                    |     |                   |
|   | NTACT\_ | 1 |   | Format = Left      |     |                   |
|   |         | 7 |   | justify, no dashes |     |                   |
|   | TE      |   |   | or spaces, pad     |     |                   |
|   | LEPHONE |   |   | with trailing      |     |                   |
|   | _NUMBER |   |   | spaces             |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Example:           |     |                   |
|   |         |   |   | 9127442286         |     |                   |
|   |         |   |   |                    |     |                   |
|   |         |   |   | Note = If blank,   |     |                   |
|   |         |   |   | pad with spaces    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | REMARKS | T | X | This is a          | Op  | There are no      |
| 5 |         | e | ( | free-form field    | tio | restrictions or   |
| 8 |         | x | 8 | for use when       | nal | requirements      |
|   |         | t | 0 | creating the       |     | regarding the     |
|   |         | , | ) | corrective action  |     | contents of this  |
|   |         | 8 |   | file.              |     | field.            |
|   |         | 0 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | REMARKS | T | X | This is a          | Op  | There are no      |
| 5 |         | e | ( | free-form field    | tio | restrictions or   |
| 9 |         | x | 8 | for use when       | nal | requirements      |
|   |         | t | 0 | creating the       |     | regarding the     |
|   |         | , | ) | corrective action  |     | contents of this  |
|   |         | 8 |   | file.              |     | field.            |
|   |         | 0 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | REMARKS | T | X | This is a          | Op  | There are no      |
| 6 |         | e | ( | free-form field    | tio | restrictions or   |
| 0 |         | x | 8 | for use when       | nal | requirements      |
|   |         | t | 0 | creating the       |     | regarding the     |
|   |         | , | ) | corrective action  |     | contents of this  |
|   |         | 8 |   | file.              |     | field.            |
|   |         | 0 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | REMARKS | T | X | This is a          | Op  | There are no      |
| 6 |         | e | ( | free-form field    | tio | restrictions or   |
| 1 |         | x | 8 | for use when       | nal | requirements      |
|   |         | t | 0 | creating the       |     | regarding the     |
|   |         | , | ) | corrective action  |     | contents of this  |
|   |         | 8 |   | file.              |     | field.            |
|   |         | 0 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| 1 | REMARKS | T | X | This is a          | Op  | There are no      |
| 6 |         | e | ( | free-form field    | tio | restrictions or   |
| 2 |         | x | 8 | for use when       | nal | requirements      |
|   |         | t | 0 | creating the       |     | regarding the     |
|   |         | , | ) | corrective action  |     | contents of this  |
|   |         | 8 |   | file.              |     | field.            |
|   |         | 0 |   |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+
| T |         | 2 | 2 |                    |     |                   |
| O |         | 0 | 0 |                    |     |                   |
| T |         | 9 | 9 |                    |     |                   |
| A |         | 4 | 4 |                    |     |                   |
| L |         |   |   |                    |     |                   |
|   |         | B | C |                    |     |                   |
|   |         | y | o |                    |     |                   |
|   |         | t | l |                    |     |                   |
|   |         | e | u |                    |     |                   |
|   |         | s | m |                    |     |                   |
|   |         |   | n |                    |     |                   |
|   |         |   | s |                    |     |                   |
+---+---------+---+---+--------------------+-----+-------------------+