[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.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 2810 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 Record Layout - 2810 File Page

8

**1 2810 FILE LAYOUT**

> This document describes the data elements that are included in the
> Form 2810 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 2810
> corrective action data using the Forms Screen Category on the CLER Web
> site. The 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]{.underline}

For requirements-related questions, please contact:

Sheila Morgan

504-255-6252

E-mail: [sheila.morgan@usda.gov]{.underline}

> 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]{.underline}

> The following table describes the format for the 2810 record layouts
> that will be generated by the National Finance Center (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 (2810) 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 Record Layout - 2810 File

# 

+---+-------------+----+----+-------------+------+-------------------+
| * | **NAME**    | *  | *  | **VALUE,    | **RE | **DEFINITION**    |
| * |             | *T | *C | FORMAT,     | QUIR |                   |
| \ |             | YP | OB | NOTES**     | ED** |                   |
| # |             | E/ | OL |             |      |                   |
| * |             | ** | ** |             |      |                   |
| * |             |    |    |             |      |                   |
|   |             | ** |    |             |      |                   |
|   |             | SI |    |             |      |                   |
|   |             | ZE |    |             |      |                   |
|   |             | ** |    |             |      |                   |
+===+=============+====+====+=============+======+===================+
| 1 | ENROLLE     | T  | X  | Value =     | Requ | This is the       |
|   | E_LAST_NAME | ex | (2 | Enrollee's  | ired | surname of the    |
|   |             | t, | 5) | last name   |      | enrollee. An      |
|   |             | 25 |    |             |      | enrollee must     |
|   |             |    |    | Format =    |      | always have a     |
|   |             |    |    | Left        |      | last name. If     |
|   |             |    |    | justify, no |      | there is case of  |
|   |             |    |    | p           |      | an enrollee       |
|   |             |    |    | unctuation, |      | having only one   |
|   |             |    |    | pad with    |      | name (e.g.,       |
|   |             |    |    | trailing    |      | Cher), then that  |
|   |             |    |    | spaces      |      | 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.     |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | ENROLLEE    | T  | X  | Value =     | Con  | First name of the |
|   | _FIRST_NAME | ex | (1 | Enrollee's  | diti | enrollee. This    |
|   |             | t, | 7) | first name  | onal | must be provided  |
|   |             | 17 |    |             |      | except in the     |
|   |             |    |    | Format =    |      | rare circumstance |
|   |             |    |    | Left        |      | that an           |
|   |             |    |    | justify, no |      | individual only   |
|   |             |    |    | p           |      | has one name      |
|   |             |    |    | unctuation, |      | (e.g., Cher).     |
|   |             |    |    | pad with    |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | E           | T  | X( | Value =     | Con  | This is the       |
|   | NROLLEE_MID | ex | 1) | Enrollee's  | diti | enrollee's middle |
|   | DLE_INITIAL | t, |    | middle      | onal | initial. If the   |
|   |             | 1  |    | initial     |      | enrollee uses one |
|   |             |    |    |             |      | name, or if the   |
|   |             |    |    | Format = No |      | enrollee does not |
|   |             |    |    | punctuation |      | have a middle     |
|   |             |    |    |             |      | name or initial,  |
|   |             |    |    | Note = If   |      | this field is     |
|   |             |    |    | blank, pad  |      | blank.            |
|   |             |    |    | with a      |      |                   |
|   |             |    |    | space       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | SOCIAL_SECU | T  | X( | Value =     | Con  | This is the       |
|   | RITY_NUMBER | ex | 9) | Enrollee's  | diti | enrollee's SSN or |
|   |             | t, |    | Social      | onal | other number that |
|   |             | 9  |    | Security    |      | is used to        |
|   |             |    |    | Number      |      | identify the      |
|   |             |    |    | (SSN) or    |      | enrollee such as  |
|   |             |    |    | other       |      | the OPM-assigned  |
|   |             |    |    | number that |      | Civil Service     |
|   |             |    |    | is used to  |      | Annuitant (CSA)   |
|   |             |    |    | identify    |      | number or the     |
|   |             |    |    | the         |      | Civil Service     |
|   |             |    |    | enrollee    |      | Final (CSF)       |
|   |             |    |    |             |      | number. If the    |
|   |             |    |    | Format =    |      | enrollee does not |
|   |             |    |    | Left        |      | want his/her SSN  |
|   |             |    |    | justify, no |      | provided to the   |
|   |             |    |    | dashes, pad |      | carrier, a pseudo |
|   |             |    |    | with        |      | SSN may be used.  |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | 123456789   |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | DA          | T  | X( | Value =     | Requ | This is the       |
|   | TE_OF_BIRTH | ex | 8) | Date of     | ired | enrollee's date   |
|   |             | t, |    | enrollee's  |      | of birth.         |
|   |             | 8  |    | birth       |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | YYYYMMDD    |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | DOMESTIC_O  | T  | X  | Value = The | Con  | This is the first |
|   | R_FOREIGN\_ | ex | (3 | first line  | diti | line of the       |
|   | HO          | t, | 5) | of the      | onal | enrollee's        |
|   | ME_STREET_1 | 35 |    | enrollee's  |      | domestic or       |
|   |             |    |    | domestic or |      | foreign street,   |
|   |             |    |    | foreign     |      | apartment number, |
|   |             |    |    | street      |      | PO box, rural     |
|   |             |    |    | address     |      | route, etc., as   |
|   |             |    |    |             |      | applicable.       |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      | This field is     |
|   |             |    |    | justify, no |      | required except   |
|   |             |    |    | p           |      | in rare cases     |
|   |             |    |    | unctuation, |      | where the address |
|   |             |    |    | pad with    |      | does not contain  |
|   |             |    |    | trailing    |      | a street or PO    |
|   |             |    |    | spaces      |      | box (i.e., John   |
|   |             |    |    |             |      | Doe, Modale, IA   |
|   |             |    |    | Example:    |      | 51556).           |
|   |             |    |    | Route 1 box |      |                   |
|   |             |    |    | 618B        |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 7 | DOMESTIC_O  | T  | X  | Value = The | Con  | This is the       |
|   | R_FOREIGN\_ | ex | (3 | second line | diti | second line of    |
|   |             | t, | 5) | of          | onal | the enrollee's    |
|   | HO          | 35 |    | enrollee's  |      | domestic or       |
|   | ME_STREET_2 |    |    | domestic or |      | foreign street,   |
|   |             |    |    | foreign     |      | apartment number, |
|   |             |    |    | street      |      | PO box, rural     |
|   |             |    |    | address     |      | route, etc., as   |
|   |             |    |    |             |      | applicable.       |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      | This field is     |
|   |             |    |    | justify, no |      | required except   |
|   |             |    |    | p           |      | in rare cases     |
|   |             |    |    | unctuation, |      | where the address |
|   |             |    |    | pad with    |      | does not contain  |
|   |             |    |    | trailing    |      | a street or PO    |
|   |             |    |    | spaces      |      | box (i.e., John   |
|   |             |    |    |             |      | Doe, Modale, IA   |
|   |             |    |    | Note = If   |      | 51556).           |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 8 | DOMESTIC_O  | T  | X  | Value = The | Con  | This is the third |
|   | R_FOREIGN\_ | ex | (3 | third line  | diti | line of the       |
|   |             | t, | 5) | of          | onal | enrollee's        |
|   | HO          | 35 |    | enrollee's  |      | domestic or       |
|   | ME_STREET_3 |    |    | domestic or |      | foreign street,   |
|   |             |    |    | foreign     |      | apartment number, |
|   |             |    |    | street      |      | PO box, rural     |
|   |             |    |    | address     |      | route, etc., as   |
|   |             |    |    |             |      | applicable.       |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      | This field is     |
|   |             |    |    | justify, no |      | required except   |
|   |             |    |    | p           |      | in rare cases     |
|   |             |    |    | unctuation, |      | where the address |
|   |             |    |    | pad with    |      | does not contain  |
|   |             |    |    | trailing    |      | a street or PO    |
|   |             |    |    | spaces      |      | box (i.e., John   |
|   |             |    |    |             |      | Doe, Modale, IA   |
|   |             |    |    | Note = If   |      | 51556).           |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 9 | DOMESTIC_O  | T  | X  | Value =     | Requ | This is the       |
|   | R_FOREIGN\_ | ex | (2 | Enrollee's  | ired | enrollee's        |
|   |             | t, | 3) | domestic or |      | domestic or       |
|   | HOME_CITY   | 23 |    | foreign     |      | foreign city for  |
|   |             |    |    | city name   |      | the enrollee's    |
|   |             |    |    |             |      | address.          |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify,    |      |                   |
|   |             |    |    | pad with    |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | Macon       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | DOMESTIC    | T  | X( | Value =     | Con  | This is the       |
| 0 | _HOME_STATE | ex | 2) | Enrollee's  | diti | abbreviation of   |
|   |             | t, |    | domestic    | onal | the domestic      |
|   |             | 2  |    | state       |      | state for the     |
|   |             |    |    | a           |      | enrollee's        |
|   |             |    |    | bbreviation |      | address.          |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example: GA |      | If the address is |
|   |             |    |    | for Georgia |      | foreign, this     |
|   |             |    |    |             |      | field is blank.   |
|   |             |    |    | Note = If   |      | If the address is |
|   |             |    |    | blank, pad  |      | domestic, this    |
|   |             |    |    | with spaces |      | field is          |
|   |             |    |    |             |      | required.         |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | FOREIGN_C   | T  | X  | Value =     | Con  | This is the name  |
| 1 | OUNTRY_NAME | ex | (2 | Enrollee's  | diti | of the enrollee's |
|   |             | t, | 3) | foreign     | onal | foreign country.  |
|   |             | 23 |    | country     |      |                   |
|   |             |    |    | name        |      | If the address is |
|   |             |    |    |             |      | domestic, this    |
|   |             |    |    | Format =    |      | field is blank.   |
|   |             |    |    | Left        |      | If the address is |
|   |             |    |    | justify,    |      | foreign, this     |
|   |             |    |    | pad with    |      | field is          |
|   |             |    |    | trailing    |      | required.         |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | Canada      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | HOME_ZIP_O  | T  | X  | Value =     | Requ | This is the       |
| 2 | R_FOREIGN\_ | ex | (1 | Domestic: 5 | ired | domestic ZIP code |
|   |             | t, | 1) | digit       |      | or foreign postal |
|   | POSTAL_CODE | 11 |    | mandatory + |      | code for the      |
|   |             |    |    | 4 optional. |      | enrollee's        |
|   |             |    |    | Foreign:    |      | address.          |
|   |             |    |    | Postal Code |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      |                   |
|   |             |    |    | dashes, pad |      |                   |
|   |             |    |    | with        |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Examples:   |      |                   |
|   |             |    |    | Domestic:   |      |                   |
|   |             |    |    | 31206 or    |      |                   |
|   |             |    |    | 312064204;  |      |                   |
|   |             |    |    | Foreign:    |      |                   |
|   |             |    |    | H2W 1J5     |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | C           | T  | X( | Value =     | Opti | This code         |
| 3 | OUNTRY_CODE | ex | 3) | Valid U.S.  | onal | identifies the    |
|   |             | t, |    | Postal      |      | country for the   |
|   |             | 3  |    | Service     |      | enrollee's        |
|   |             |    |    | country     |      | address.          |
|   |             |    |    | code        |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | PAYROL      | T  | X( | Value =     | Requ | This number is    |
| 4 | L_OFFICE_ID | ex | 8) | Payroll     | ired | assigned by       |
|   |             | t, |    | Office      |      | Treasury and OPM  |
|   |             | 8  |    | Ide         |      | to the            |
|   |             |    |    | ntification |      | organization that |
|   |             |    |    |             |      | is responsible    |
|   |             |    |    |             |      | for coordinating  |
|   |             |    |    |             |      | the enrollee's    |
|   |             |    |    |             |      | FEHB coverage and |
|   |             |    |    |             |      | premium           |
|   |             |    |    |             |      | collections.      |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | FILLER      | T  | X( | Value = Pad | Requ | This field is     |
| 5 |             | ex | 7) | with spaces | ired | reserved for      |
|   |             | t, |    |             |      | future use.       |
|   |             | 7  |    |             |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | FEHB_ENRO   | T  | X( | Value =     | Requ | This code defines |
| 6 | LLMENT_CODE | ex | 3) | Positions 1 | ired | the plan and      |
|   |             | t, |    | and 2 equal |      | option of the     |
|   |             | 3  |    | the plan;   |      | enrollee.         |
|   |             |    |    | 3^rd^       |      |                   |
|   |             |    |    | position is |      |                   |
|   |             |    |    | plan option |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | EF          | T  | X( | Value =     | Requ | This is the date  |
| 7 | FECTIVE_DAT | ex | 8) | Effective   | ired | the action        |
|   | E_OF_ACTION | t, |    | date of     |      | becomes           |
|   |             | 8  |    | action      |      | effective.        |
|   |             |    |    |             |      |                   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | YYYYMMDD    |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | 20020101    |      |                   |
|   |             |    |    | (January 1, |      |                   |
|   |             |    |    | 2002)       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | CS          | T  | X( | Value =     | Con  | This is the Civil |
| 8 | A_ANNUITY_C | ex | 9) | Valid       | diti | Service Annuitant |
|   | LAIM_NUMBER | t, |    | annuitant   | onal | number that is    |
|   |             | 9  |    | claim       |      | assigned to the   |
|   |             |    |    | number      |      | enrollee by OPM.  |
|   |             |    |    |             |      | This field is     |
|   |             |    |    | Note = If   |      | required for      |
|   |             |    |    | blank, pad  |      | annuitants only.  |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 1 | CSF_SURVIVO | T  | X( | Value =     | Con  | This is the Civil |
| 9 | R_ANNUITY\_ | ex | 9) | Valid       | diti | Service Final     |
|   |             | t, |    | survivor    | onal | number that is    |
|   | C           | 9  |    | annuitant   |      | assigned to the   |
|   | LAIM_NUMBER |    |    | claim       |      | enrollee by OPM.  |
|   |             |    |    | number      |      | This field is     |
|   |             |    |    |             |      | required for      |
|   |             |    |    | Note = If   |      | survivor          |
|   |             |    |    | blank, pad  |      | annuitants only.  |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | OTHER_PAYRO | T  | X( | Value =     | Opti | This field is for |
| 0 | LL_OFFICE\_ | ex | 9) | Deceased    | onal | OPM's use to      |
|   |             | t, |    | enrollee's  |      | identify the      |
|   | ENROLLEE_ID | 9  |    | SSN         |      | deceased's SSN as |
|   |             |    |    |             |      | a carrier control |
|   |             |    |    | Format =    |      | number for        |
|   |             |    |    | Left        |      | survivor          |
|   |             |    |    | justify, no |      | annuitants.       |
|   |             |    |    | dashes, pad |      |                   |
|   |             |    |    | with        |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | TERMINATION | T  | X( | Value = Y   | Con  | This code         |
| 1 |             | ex | 1) |             | diti | indicates if      |
|   |             | t, |    | Y = yes     | onal | coverage is       |
|   |             | 1  |    |             |      | terminated.       |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with a      |      |                   |
|   |             |    |    | space       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | TERMI       | T  | X( | Value =     | Con  | This is the date  |
| 2 | NATION_DUE_ | ex | 8) | Date of     | diti | the enrollee      |
|   | TO_DEATH_DA | t, |    | death       | onal | died.             |
|   | TE_OF_DEATH | 8  |    |             |      |                   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | YYYYMMDD    |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | TRANSFER_IN | T  | X( | Value = Y   | Con  | This code         |
| 3 |             | ex | 1) |             | diti | indicates if      |
|   |             | t, |    | Y = yes     | onal | another payroll   |
|   |             | 1  |    |             |      | office or         |
|   |             |    |    | Note = If   |      | retirement system |
|   |             |    |    | blank, pad  |      | has accepted the  |
|   |             |    |    | with a      |      | transfer of the   |
|   |             |    |    | space       |      | enrollment.       |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | RE          | T  | X( | Value = Y   | Con  | This code         |
| 4 | INSTATEMENT | ex | 1) |             | diti | indicates if the  |
|   |             | t, |    | Y = yes     | onal | enrollment has    |
|   |             | 1  |    |             |      | been reinstated.  |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with a      |      |                   |
|   |             |    |    | space       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | CHANGE_I    | T  | X( | Value = Y   | Con  | This code         |
| 5 | N_NAME_OF\_ | ex | 1) |             | diti | indicates if (1)  |
|   |             | t, |    | Y = yes     | onal | an enrollee's     |
|   | ENROLLEE    | 1  |    |             |      | name has changed, |
|   |             |    |    | Note = If   |      | (2) the           |
|   |             |    |    | blank, pad  |      | enrollment has    |
|   |             |    |    | with a      |      | changed from the  |
|   |             |    |    | space       |      | enrollee's name   |
|   |             |    |    |             |      | to the name of    |
|   |             |    |    |             |      | the survivor      |
|   |             |    |    |             |      | annuitant, or (3) |
|   |             |    |    |             |      | the enrollment    |
|   |             |    |    |             |      | has changed from  |
|   |             |    |    |             |      | the survivor      |
|   |             |    |    |             |      | annuitant's name  |
|   |             |    |    |             |      | to the name of    |
|   |             |    |    |             |      | another survivor  |
|   |             |    |    |             |      | annuitant.        |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | NEW_ENROLLE | T  | X  | Value =     | Con  | This is the       |
| 6 | E_LAST_NAME | ex | (2 | Enrollee's  | diti | surname of the    |
|   |             | t, | 5) | new last    | onal | enrollee's new    |
|   |             | 25 |    | name        |      | last name or the  |
|   |             |    |    |             |      | survivor          |
|   |             |    |    | Format =    |      | annuitant's last  |
|   |             |    |    | Left        |      | name. An enrollee |
|   |             |    |    | justify, no |      | or survivor       |
|   |             |    |    | p           |      | annuitant must    |
|   |             |    |    | unctuation, |      | always have a     |
|   |             |    |    | pad with    |      | last name. If     |
|   |             |    |    | trailing    |      | there is a case   |
|   |             |    |    | spaces      |      | of an enrollee or |
|   |             |    |    |             |      | survivor          |
|   |             |    |    | Note = If   |      | annuitant having  |
|   |             |    |    | blank, pad  |      | only one name     |
|   |             |    |    | with spaces |      | (e.g., Cher),     |
|   |             |    |    |             |      | then that one     |
|   |             |    |    |             |      | name must be      |
|   |             |    |    |             |      | placed in this    |
|   |             |    |    |             |      | field. If the     |
|   |             |    |    |             |      | enrollee or       |
|   |             |    |    |             |      | survivor          |
|   |             |    |    |             |      | annuitant 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                |
|   |             |    |    |             |      | CHANGE_IN         |
|   |             |    |    |             |      | _NAME_OF_ENROLLEE |
|   |             |    |    |             |      | is Y, and the     |
|   |             |    |    |             |      | enrollee has a    |
|   |             |    |    |             |      | new last name, or |
|   |             |    |    |             |      | if the enrollment |
|   |             |    |    |             |      | has changed from  |
|   |             |    |    |             |      | the enrollee's    |
|   |             |    |    |             |      | name to the name  |
|   |             |    |    |             |      | of the survivor   |
|   |             |    |    |             |      | annuitant, this   |
|   |             |    |    |             |      | field is          |
|   |             |    |    |             |      | required.         |
|   |             |    |    |             |      |                   |
|   |             |    |    |             |      | This field is     |
|   |             |    |    |             |      | required when     |
|   |             |    |    |             |      | reporting changes |
|   |             |    |    |             |      | in name where     |
|   |             |    |    |             |      | change of         |
|   |             |    |    |             |      | coverage within a |
|   |             |    |    |             |      | plan by 2809 is   |
|   |             |    |    |             |      | not involved.     |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | N           | T  | X  | Value =     | Con  | If                |
| 7 | EW_ENROLLEE | ex | (1 | Enrollee's  | diti | CHANGE_IN         |
|   | _FIRST_NAME | t, | 7) | new first   | onal | _NAME_OF_ENROLLEE |
|   |             | 17 |    | name        |      | is Y, the first   |
|   |             |    |    |             |      | name of the       |
|   |             |    |    | Format =    |      | enrollee or       |
|   |             |    |    | Left        |      | survivor          |
|   |             |    |    | justify, no |      | annuitant must be |
|   |             |    |    | p           |      | provided except   |
|   |             |    |    | unctuation, |      | in the rare       |
|   |             |    |    | pad with    |      | circumstance that |
|   |             |    |    | trailing    |      | an individual     |
|   |             |    |    | spaces      |      | only has one name |
|   |             |    |    |             |      | (e.g., Cher).     |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | NEW_ENROLL  | T  | X( | Value =     | Con  | If                |
| 8 | EE_MIDDLE\_ | ex | 1) | Enrollee's  | diti | CHANGE_IN         |
|   |             | t, |    | new middle  | onal | _NAME_OF_ENROLLEE |
|   | INITIAL     | 1  |    | initial     |      | is Y, the middle  |
|   |             |    |    |             |      | initial of the    |
|   |             |    |    | Format = No |      | enrollee or       |
|   |             |    |    | punctuation |      | survivor          |
|   |             |    |    |             |      | annuitant must be |
|   |             |    |    | Note = If   |      | provided. If the  |
|   |             |    |    | blank, pad  |      | enrollee or       |
|   |             |    |    | with a      |      | survivor          |
|   |             |    |    | space       |      | annuitant uses    |
|   |             |    |    |             |      | one name, or if   |
|   |             |    |    |             |      | the enrollee or   |
|   |             |    |    |             |      | survivor          |
|   |             |    |    |             |      | annuitant does    |
|   |             |    |    |             |      | not have a middle |
|   |             |    |    |             |      | name or initial,  |
|   |             |    |    |             |      | this field is     |
|   |             |    |    |             |      | blank.            |
+---+-------------+----+----+-------------+------+-------------------+
| 2 | NEW_ENROLLE | T  | X( | Value =     | Con  | If                |
| 9 | E_DATE_OF\_ | ex | 8) | Enrollee's  | diti | CHANGE_IN         |
|   |             | t, |    | date of     | onal | _NAME_OF_ENROLLEE |
|   | BIRTH       | 8  |    | birth       |      | is Y, the date of |
|   |             |    |    |             |      | birth is          |
|   |             |    |    | Format =    |      | required.         |
|   |             |    |    | YYYYMMDD    |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | NEW_ENROLL  | T  | X( | Value =     | Con  | If                |
| 0 | EE_SOCIAL\_ | ex | 9) | Enrollee's  | diti | CHANGE_IN         |
|   |             | t, |    | SSN or      | onal | _NAME_OF_ENROLLEE |
|   | SECU        | 9  |    | other       |      | is Y, the SSN is  |
|   | RITY_NUMBER |    |    | number that |      | used to identify  |
|   |             |    |    | is used to  |      | the enrollee or   |
|   |             |    |    | identify    |      | survivor          |
|   |             |    |    | the         |      | annuitant. If the |
|   |             |    |    | enrollee    |      | enrollee or       |
|   |             |    |    |             |      | survivor          |
|   |             |    |    | Format =    |      | annuitant does    |
|   |             |    |    | Left        |      | not want his/her  |
|   |             |    |    | justify, no |      | SSN provided to   |
|   |             |    |    | dashes, pad |      | the carrier, a    |
|   |             |    |    | with        |      | pseudo SSN may be |
|   |             |    |    | trailing    |      | used.             |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | 123456789   |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | NEW_ENROLL  | T  | X( | Value = M   | Con  | If                |
| 1 | EE_SEX_CODE | ex | 1) | or F        | diti | CHANGE_IN         |
|   |             | t, |    |             | onal | _NAME_OF_ENROLLEE |
|   |             | 1  |    | M = male    |      | is Y, this field  |
|   |             |    |    |             |      | is required, and  |
|   |             |    |    | F = female  |      | indicates the sex |
|   |             |    |    |             |      | of the enrollee   |
|   |             |    |    | Note = If   |      | or survivor       |
|   |             |    |    | blank, pad  |      | annuitant.        |
|   |             |    |    | with a      |      |                   |
|   |             |    |    | space       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | N           | T  | X  | Value = The | Con  | If the            |
| 2 | EW_ENROLLEE | ex | (3 | first line  | diti | CHANGE_IN         |
|   | _DOMESTIC\_ | t, | 5) | of the      | onal | _NAME_OF_ENROLLEE |
|   |             | 35 |    | enrollee's  |      | is Y, this field  |
|   | OR          |    |    | domestic or |      | is completed if   |
|   | _FOREIGN_HO |    |    | foreign     |      | the first line of |
|   | ME_STREET_1 |    |    | street      |      | the street        |
|   |             |    |    | address     |      | address for the   |
|   |             |    |    |             |      | enrollee or       |
|   |             |    |    | Format =    |      | survivor          |
|   |             |    |    | Left        |      | annuitant is      |
|   |             |    |    | justify, no |      | different from    |
|   |             |    |    | p           |      | the data          |
|   |             |    |    | unctuation, |      | contained in the  |
|   |             |    |    | pad with    |      | DOMESTIC_OR_FORE  |
|   |             |    |    | trailing    |      | IGN_HOME_STREET_1 |
|   |             |    |    | spaces      |      | field.            |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | Route 1 box |      |                   |
|   |             |    |    | 618B        |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | N           | T  | X  | Value = The | Con  | If the            |
| 3 | EW_ENROLLEE | ex | (3 | second line | diti | CHANGE_IN         |
|   | _DOMESTIC\_ | t, | 5) | of the      | onal | _NAME_OF_ENROLLEE |
|   |             | 35 |    | enrollee's  |      | is Y, this field  |
|   | OR          |    |    | domestic or |      | is completed if   |
|   | _FOREIGN_HO |    |    | foreign     |      | the second line   |
|   | ME_STREET_2 |    |    | street      |      | of the street     |
|   |             |    |    | address     |      | address for the   |
|   |             |    |    |             |      | enrollee or       |
|   |             |    |    | Format =    |      | survivor          |
|   |             |    |    | Left        |      | annuitant is      |
|   |             |    |    | justify, no |      | different from    |
|   |             |    |    | p           |      | the data          |
|   |             |    |    | unctuation, |      | contained in the  |
|   |             |    |    | pad with    |      | DOMESTIC_OR_FORE  |
|   |             |    |    | trailing    |      | IGN_HOME_STREET_2 |
|   |             |    |    | spaces      |      | field.            |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | N           | T  | X  | Value = The | Con  | If the            |
| 4 | EW_ENROLLEE | ex | (3 | third line  | diti | CHANGE_IN         |
|   | _DOMESTIC\_ | t, | 5) | of          | onal | _NAME_OF_ENROLLEE |
|   |             | 35 |    | enrollee's  |      | is Y, this field  |
|   | OR          |    |    | domestic or |      | is completed if   |
|   | _FOREIGN_HO |    |    | foreign     |      | the third line of |
|   | ME_STREET_3 |    |    | street      |      | the street        |
|   |             |    |    | address     |      | address for the   |
|   |             |    |    |             |      | enrollee or       |
|   |             |    |    | Format =    |      | survivor          |
|   |             |    |    | Left        |      | annuitant is      |
|   |             |    |    | justify, no |      | different from    |
|   |             |    |    | p           |      | the data          |
|   |             |    |    | unctuation, |      | contained in the  |
|   |             |    |    | pad with    |      | DOMESTIC_OR_FORE  |
|   |             |    |    | trailing    |      | IGN_HOME_STREET_3 |
|   |             |    |    | spaces      |      | field.            |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | N           | T  | X  | Value =     | Con  | If the            |
| 5 | EW_ENROLLEE | ex | (2 | Enrollee's  | diti | CHANGE_IN         |
|   | _DOMESTIC\_ | t, | 3) | domestic or | onal | _NAME_OF_ENROLLEE |
|   |             | 23 |    | foreign     |      | is Y, this field  |
|   | OR_FOREIG   |    |    | city name   |      | is completed if   |
|   | N_HOME_CITY |    |    |             |      | the domestic or   |
|   |             |    |    | Format =    |      | foreign city name |
|   |             |    |    | Left        |      | for the           |
|   |             |    |    | justify,    |      | enrollee's or     |
|   |             |    |    | pad with    |      | survivor          |
|   |             |    |    | trailing    |      | annuitant's       |
|   |             |    |    | spaces      |      | address is        |
|   |             |    |    |             |      | different from    |
|   |             |    |    | Example:    |      | the data          |
|   |             |    |    | Macon       |      | contained in the  |
|   |             |    |    |             |      | DOMESTIC_OR_      |
|   |             |    |    | Note = If   |      | FOREIGN_HOME_CITY |
|   |             |    |    | blank, pad  |      | field.            |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | N           | T  | X( | Value =     | Con  | If the            |
| 6 | EW_ENROLLEE | ex | 2) | Enrollee's  | diti | CHANGE_IN         |
|   | _DOMESTIC\_ | t, |    | domestic    | onal | _NAME_OF_ENROLLEE |
|   |             | 2  |    | state       |      | is Y, this field  |
|   | HOME_STATE  |    |    | a           |      | is completed if   |
|   |             |    |    | bbreviation |      | the domestic home |
|   |             |    |    |             |      | state             |
|   |             |    |    | Example: GA |      | abbreviation for  |
|   |             |    |    | for Georgia |      | the enrollee's or |
|   |             |    |    |             |      | survivor          |
|   |             |    |    | Note = If   |      | annuitant's       |
|   |             |    |    | blank, pad  |      | address is        |
|   |             |    |    | with spaces |      | different from    |
|   |             |    |    |             |      | the data          |
|   |             |    |    |             |      | contained in the  |
|   |             |    |    |             |      | DO                |
|   |             |    |    |             |      | MESTIC_HOME_STATE |
|   |             |    |    |             |      | field.            |
|   |             |    |    |             |      |                   |
|   |             |    |    |             |      | If the address is |
|   |             |    |    |             |      | foreign, this     |
|   |             |    |    |             |      | field is blank.   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | NEW_ENROLLE | T  | X  | Value =     | Con  | If the            |
| 7 | E_FOREIGN\_ | ex | (2 | Enrollee's  | diti | CHANGE_IN         |
|   |             | t, | 3) | foreign     | onal | _NAME_OF_ENROLLEE |
|   | C           | 23 |    | country     |      | is Y, this field  |
|   | OUNTRY_NAME |    |    | name        |      | is completed if   |
|   |             |    |    |             |      | the foreign       |
|   |             |    |    | Format =    |      | country name for  |
|   |             |    |    | Left        |      | the enrollee's or |
|   |             |    |    | justify,    |      | survivor          |
|   |             |    |    | pad with    |      | annuitant's       |
|   |             |    |    | trailing    |      | address is        |
|   |             |    |    | spaces      |      | different from    |
|   |             |    |    |             |      | the data          |
|   |             |    |    | Example:    |      | contained in the  |
|   |             |    |    | Canada      |      | FOR               |
|   |             |    |    |             |      | EIGN_COUNTRY_NAME |
|   |             |    |    | Note = If   |      | field.            |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      | If the address is |
|   |             |    |    |             |      | domestic, this    |
|   |             |    |    |             |      | field is blank.   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | N           | T  | X  | Value =     | Con  | If the            |
| 8 | EW_ENROLLEE | ex | (1 | Enrollee's  | diti | CHANGE_IN         |
|   | _HOME_ZIP\_ | t, | 1) | valid       | onal | _NAME_OF_ENROLLEE |
|   |             | 11 |    | domestic    |      | is Y, this field  |
|   | OR_FOREIGN_ |    |    | ZIP Code or |      | is completed if   |
|   | POSTAL_CODE |    |    | foreign     |      | the home ZIP or   |
|   |             |    |    | postal code |      | foreign postal    |
|   |             |    |    |             |      | code for the      |
|   |             |    |    | Format =    |      | enrollee's or     |
|   |             |    |    | Left        |      | survivor          |
|   |             |    |    | justify, no |      | annuitant's       |
|   |             |    |    | dashes, pad |      | address is        |
|   |             |    |    | with        |      | different from    |
|   |             |    |    | trailing    |      | the data          |
|   |             |    |    | spaces      |      | contained in the  |
|   |             |    |    |             |      | HOME_ZIP_OR_FO    |
|   |             |    |    | Examples:   |      | REIGN_POSTAL_CODE |
|   |             |    |    | Domestic:   |      | field.            |
|   |             |    |    | 31206 or    |      |                   |
|   |             |    |    | 312064204;  |      |                   |
|   |             |    |    | Foreign:    |      |                   |
|   |             |    |    | H2W 1J5     |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 3 | NEW_ENROLLE | T  | X( | Value =     | Opti | If the            |
| 9 | E_COUNTRY\_ | ex | 3) | Enrollee's  | onal | CHANGE_IN         |
|   |             | t, |    | valid U.S.  |      | _NAME_OF_ENROLLEE |
|   | CODE        | 3  |    | Postal      |      | is Y, this field  |
|   |             |    |    | Service     |      | is completed if   |
|   |             |    |    | country     |      | the country code  |
|   |             |    |    | code        |      | for the           |
|   |             |    |    |             |      | enrollee's or     |
|   |             |    |    | Note = If   |      | survivor          |
|   |             |    |    | blank, pad  |      | annuitant's       |
|   |             |    |    | with spaces |      | address is        |
|   |             |    |    |             |      | different from    |
|   |             |    |    |             |      | the data          |
|   |             |    |    |             |      | contained in the  |
|   |             |    |    |             |      | COUNTRY_CODE      |
|   |             |    |    |             |      | field.            |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | CHANGE_IN_E | T  | X( | Value = Y   | Con  | This code         |
| 0 | NROLLMENT\_ | ex | 1) |             | diti | indicates if the  |
|   |             | t, |    | Y = yes     | onal | survivor          |
|   | ANNUITA     | 1  |    |             |      | annuitant's       |
|   | NT/SURVIVOR |    |    | Note = If   |      | enrollment code   |
|   |             |    |    | blank, pad  |      | has changed.      |
|   |             |    |    | with a      |      |                   |
|   |             |    |    | space       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | FILLER      | T  | X( | Value = Pad | Requ | This field is     |
| 1 |             | ex | 7) | with spaces | ired | reserved for      |
|   |             | t, |    |             |      | future use.       |
|   |             | 7  |    |             |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | NEW_FEHB_E  | T  | X( | Value =     | Con  | This code defines |
| 2 | NROLLMENT\_ | ex | 3) | positions 1 | diti | the plan and      |
|   |             | t, |    | and 2 equal | onal | option of the     |
|   | CODE        | 3  |    | the plan;   |      | survivor          |
|   |             |    |    | 3^rd^       |      | annuitant.        |
|   |             |    |    | position is |      |                   |
|   |             |    |    | plan option |      | If the survivor   |
|   |             |    |    |             |      | annuitant's       |
|   |             |    |    | Note = If   |      | enrollment code   |
|   |             |    |    | blank, pad  |      | has changed, this |
|   |             |    |    | with spaces |      | field is          |
|   |             |    |    |             |      | required.         |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | AGENCY_ID   | T  | X( | Value =     | Con  | Required if       |
| 3 |             | ex | 4) | 4-position  | diti | available.        |
|   |             | t, |    | agency      | onal |                   |
|   |             | 4  |    | identifier  |      | The agency and,   |
|   |             |    |    |             |      | where applicable, |
|   |             |    |    | Note = If   |      | the               |
|   |             |    |    | blank, pad  |      | administrative    |
|   |             |    |    | with spaces |      | 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: |
|   |             |    |    |             |      |                   |
|   |             |    |    |             |      | [h                |
|   |             |    |    |             |      | ttp://www.opm.gov |
|   |             |    |    |             |      | /feddata/guidance |
|   |             |    |    |             |      | .htm](http://www. |
|   |             |    |    |             |      | opm.gov/feddata/h |
|   |             |    |    |             |      | tml/datastan.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.           |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | AGENCY_USE  | T  | X  | This is a   | Opti | There are no      |
| 4 |             | ex | (1 | free-form   | onal | restrictions or   |
|   |             | t, | 5) | field for   |      | requirements      |
|   |             | 15 |    | use when    |      | regarding the     |
|   |             |    |    | creating    |      | contents of this  |
|   |             |    |    | the         |      | field.            |
|   |             |    |    | corrective  |      |                   |
|   |             |    |    | action      |      |                   |
|   |             |    |    | file.       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | PERSONNE    | T  | X( | Value =     | Con  | Required if       |
| 5 | L_OFFICE_ID | ex | 4) | Personnel   | diti | available.        |
|   |             | t, |    | Office      | onal |                   |
|   |             | 4  |    | identifier  |      | The               |
|   |             |    |    |             |      | identification of |
|   |             |    |    | Format =    |      | the Federal       |
|   |             |    |    | Left        |      | civilian          |
|   |             |    |    | justify,    |      | personnel office  |
|   |             |    |    | pad with    |      | authorized to     |
|   |             |    |    | trailing    |      | appoint and       |
|   |             |    |    | spaces      |      | separate an       |
|   |             |    |    |             |      | employee, and to  |
|   |             |    |    | Note = If   |      | the extent such   |
|   |             |    |    | blank, pad  |      | functions have    |
|   |             |    |    | with spaces |      | been delegated,   |
|   |             |    |    |             |      | prepare personnel |
|   |             |    |    |             |      | actions, maintain |
|   |             |    |    |             |      | official          |
|   |             |    |    |             |      | personnel         |
|   |             |    |    |             |      | records, and      |
|   |             |    |    |             |      | administer        |
|   |             |    |    |             |      | programs for      |
|   |             |    |    |             |      | 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.           |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | AGENCY_NAME | T  | X  | Value = The | Requ | This is the name  |
| 6 |             | ex | (3 | name of the | ired | of the employing, |
|   |             | t, | 5) | enrollee's  |      | personnel, or     |
|   |             | 35 |    | employing,  |      | point of contact  |
|   |             |    |    | personnel,  |      | office that is    |
|   |             |    |    | or point of |      | responsible for   |
|   |             |    |    | contact     |      | coordinating the  |
|   |             |    |    | office      |      | enrollee's FEHB   |
|   |             |    |    |             |      | coverage.         |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      |                   |
|   |             |    |    | p           |      |                   |
|   |             |    |    | unctuation, |      |                   |
|   |             |    |    | pad with    |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | DOMESTIC_O  | T  | X  | Value = The | Con  | This is the first |
| 7 | R_FOREIGN\_ | ex | (3 | first line  | diti | line of the       |
|   |             | t, | 5) | of the      | onal | domestic or       |
|   | AGEN        | 35 |    | employing,  |      | foreign street,   |
|   | CY_STREET_1 |    |    | personnel,  |      | PO box, rural     |
|   |             |    |    | or point of |      | route, etc., of   |
|   |             |    |    | contact     |      | the employing,    |
|   |             |    |    | office's    |      | personnel, or     |
|   |             |    |    | domestic or |      | point of contact  |
|   |             |    |    | foreign     |      | office that is    |
|   |             |    |    | street      |      | responsible for   |
|   |             |    |    | address     |      | coordinating the  |
|   |             |    |    |             |      | enrollee's FEHB   |
|   |             |    |    | Format =    |      | coverage.         |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      | This field is     |
|   |             |    |    | p           |      | required except   |
|   |             |    |    | unctuation, |      | in rare cases     |
|   |             |    |    | pad with    |      | where the address |
|   |             |    |    | trailing    |      | does not contain  |
|   |             |    |    | spaces      |      | a street or PO    |
|   |             |    |    |             |      | box (i.e., John   |
|   |             |    |    | Example:    |      | Doe, Modale, IA   |
|   |             |    |    | Route 1 Box |      | 51556).           |
|   |             |    |    | 618B        |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | DOMESTIC_O  | T  | X  | Value = The | Con  | This is the       |
| 8 | R_FOREIGN\_ | ex | (3 | second line | diti | second line of    |
|   | AGEN        | t, | 5) | of the      | onal | the domestic or   |
|   | CY_STREET_2 | 35 |    | employing,  |      | foreign street,   |
|   |             |    |    | personnel,  |      | PO box, rural     |
|   |             |    |    | or point of |      | route, etc., of   |
|   |             |    |    | contact     |      | the employing,    |
|   |             |    |    | office's    |      | personnel, or     |
|   |             |    |    | domestic or |      | point of contact  |
|   |             |    |    | foreign     |      | office that is    |
|   |             |    |    | street      |      | responsible for   |
|   |             |    |    | address     |      | coordinating the  |
|   |             |    |    |             |      | enrollee's FEHB   |
|   |             |    |    | Format =    |      | coverage.         |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      | This field is     |
|   |             |    |    | p           |      | required except   |
|   |             |    |    | unctuation, |      | in rare cases     |
|   |             |    |    | pad with    |      | where the address |
|   |             |    |    | trailing    |      | does not contain  |
|   |             |    |    | spaces      |      | a street or PO    |
|   |             |    |    |             |      | box (i.e., John   |
|   |             |    |    | Note = If   |      | Doe, Modale, IA   |
|   |             |    |    | blank, pad  |      | 51556).           |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 4 | DOMESTIC_O  | T  | X  | Value = The | Con  | This is the third |
| 9 | R_FOREIGN\_ | ex | (3 | third line  | diti | line of the       |
|   | AGEN        | t, | 5) | of the      | onal | domestic or       |
|   | CY_STREET_3 | 35 |    | employing,  |      | foreign street,   |
|   |             |    |    | personnel,  |      | PO box, rural     |
|   |             |    |    | or point of |      | route, etc., of   |
|   |             |    |    | contact     |      | the employing,    |
|   |             |    |    | office's    |      | personnel, or     |
|   |             |    |    | domestic or |      | point of contact  |
|   |             |    |    | foreign     |      | office that is    |
|   |             |    |    | street      |      | responsible for   |
|   |             |    |    | address     |      | coordinating the  |
|   |             |    |    |             |      | enrollee's FEHB   |
|   |             |    |    | Format =    |      | coverage.         |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      | This field is     |
|   |             |    |    | p           |      | required except   |
|   |             |    |    | unctuation, |      | in rare cases     |
|   |             |    |    | pad with    |      | where the address |
|   |             |    |    | trailing    |      | does not contain  |
|   |             |    |    | spaces      |      | a street or PO    |
|   |             |    |    |             |      | box (i.e., John   |
|   |             |    |    | Note = If   |      | Doe, Modale, IA   |
|   |             |    |    | blank, pad  |      | 51556).           |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | DOMESTIC_O  | T  | X  | Value =     | Requ | This is the       |
| 0 | R_FOREIGN\_ | ex | (2 | Employing,  | ired | domestic or       |
|   | AGENCY_CITY | t, | 3) | personnel,  |      | foreign city in   |
|   |             | 23 |    | or point of |      | which the         |
|   |             |    |    | contact     |      | enrollee's        |
|   |             |    |    | office's    |      | employing,        |
|   |             |    |    | domestic or |      | personnel, or     |
|   |             |    |    | foreign     |      | point of contact  |
|   |             |    |    | city name   |      | office is         |
|   |             |    |    |             |      | located.          |
|   |             |    |    | Format: =   |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify,    |      |                   |
|   |             |    |    | pad with    |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | Macon       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | DOMESTIC_A  | T  | X( | Value =     | Con  | This is the       |
| 1 | GENCY_STATE | ex | 2) | Employing,  | diti | abbreviation of   |
|   |             | t, |    | personnel,  | onal | the domestic      |
|   |             | 2  |    | or point of |      | state in which    |
|   |             |    |    | contact     |      | the enrollee's    |
|   |             |    |    | office's    |      | employing,        |
|   |             |    |    | domestic    |      | personnel, or     |
|   |             |    |    | state       |      | point of contact  |
|   |             |    |    | a           |      | office is         |
|   |             |    |    | bbreviation |      | located.          |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example: GA |      | If the address is |
|   |             |    |    | for Georgia |      | foreign, this     |
|   |             |    |    |             |      | field is blank.   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | FOREI       | T  | X  | Value =     | Con  | This is the name  |
| 2 | GN_AGENCY\_ | ex | (2 | Employing,  | diti | of the employing, |
|   |             | t, | 3) | personnel,  | onal | personnel, or     |
|   | C           | 23 |    | or point of |      | point of contact  |
|   | OUNTRY_NAME |    |    | contact     |      | office's foreign  |
|   |             |    |    | office's    |      | country.          |
|   |             |    |    | foreign     |      |                   |
|   |             |    |    | country     |      | If the address is |
|   |             |    |    | name        |      | domestic, this    |
|   |             |    |    |             |      | field is blank.   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify,    |      |                   |
|   |             |    |    | pad with    |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | Canada      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | AG          | T  | X  | Value =     | Requ | This is the       |
| 3 | ENCY_DOMEST | ex | (1 | Employing,  | ired | domestic ZIP code |
|   | IC_ZIP_OR\_ | t, | 1) | personnel,  |      | or foreign postal |
|   |             | 11 |    | or point of |      | code for the      |
|   | FOREIGN_    |    |    | contact     |      | employing,        |
|   | POSTAL_CODE |    |    | office's    |      | personnel, or     |
|   |             |    |    | valid       |      | point of contact  |
|   |             |    |    | domestic    |      | office's address. |
|   |             |    |    | ZIP Code or |      |                   |
|   |             |    |    | foreign     |      |                   |
|   |             |    |    | postal code |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      |                   |
|   |             |    |    | dashes, pad |      |                   |
|   |             |    |    | with        |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Examples:   |      |                   |
|   |             |    |    | Domestic:   |      |                   |
|   |             |    |    | 31206 or    |      |                   |
|   |             |    |    | 312064204;  |      |                   |
|   |             |    |    | Foreign:    |      |                   |
|   |             |    |    | H2W 1J5     |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | AGENCY_C    | T  | X( | Value =     | Opti | This code         |
| 4 | OUNTRY_CODE | ex | 3) | Valid U.S.  | onal | identifies the    |
|   |             | t, |    | Postal      |      | country for the   |
|   |             | 3  |    | Service     |      | employing,        |
|   |             |    |    | country     |      | personnel, or     |
|   |             |    |    | code        |      | point of contact  |
|   |             |    |    |             |      | office's address. |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | AUTHORIZ    | T  | X  | Value =     | Requ | This is the       |
| 5 | ED_AGENCY\_ | ex | (2 | Agency      | ired | surname of the    |
|   |             | t, | 5) | official's  |      | agency official   |
|   | OFFICIA     | 25 |    | last name   |      | who is authorized |
|   | L_LAST_NAME |    |    |             |      | to sign the 2810. |
|   |             |    |    | Format =    |      | The agency        |
|   |             |    |    | Left        |      | official must     |
|   |             |    |    | justify, no |      | always have a     |
|   |             |    |    | p           |      | last name. If     |
|   |             |    |    | unctuation, |      | there is a case   |
|   |             |    |    | pad with    |      | of an agency      |
|   |             |    |    | trailing    |      | official having   |
|   |             |    |    | spaces      |      | only one name     |
|   |             |    |    |             |      | (e.g., Cher),     |
|   |             |    |    |             |      | then that one     |
|   |             |    |    |             |      | name must be      |
|   |             |    |    |             |      | placed in this    |
|   |             |    |    |             |      | field. If the     |
|   |             |    |    |             |      | 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.     |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | AUTHORIZ    | T  | X  | Value =     | Con  | First name of the |
| 6 | ED_AGENCY\_ | ex | (1 | Agency      | diti | agency official   |
|   |             | t, | 7) | official's  | onal | who is authorized |
|   | OFFICIAL    | 17 |    | first name  |      | to sign the 2810. |
|   | _FIRST_NAME |    |    |             |      | This must be      |
|   |             |    |    | Format =    |      | provided except   |
|   |             |    |    | Left        |      | in the rare       |
|   |             |    |    | justify, no |      | circumstance that |
|   |             |    |    | p           |      | the agency        |
|   |             |    |    | unctuation, |      | official only has |
|   |             |    |    | pad with    |      | one name (e.g.,   |
|   |             |    |    | trailing    |      | Cher).            |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | AUTHORIZ    | T  | X( | Value =     | Con  | This is the       |
| 7 | ED_AGENCY\_ | ex | 1) | Agency      | diti | middle initial of |
|   |             | t, |    | official's  | onal | the agency        |
|   | O           | 1  |    | middle      |      | official who is   |
|   | FFICIAL_MID |    |    | initial     |      | authorized to     |
|   | DLE_INITIAL |    |    |             |      | sign the 2810. If |
|   |             |    |    | Format = No |      | the agency        |
|   |             |    |    | punctuation |      | official uses one |
|   |             |    |    |             |      | name, or if the   |
|   |             |    |    | Note = If   |      | agency official   |
|   |             |    |    | blank, pad  |      | does not have a   |
|   |             |    |    | with a      |      | middle name or    |
|   |             |    |    | space       |      | initial, this     |
|   |             |    |    |             |      | field is blank.   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | AUTHORIZ    | T  | X( | Value =     | Requ | The date the      |
| 8 | ED_AGENCY\_ | ex | 8) | Date of     | ired | authorized agency |
|   |             | t, |    | signature   |      | official signed   |
|   | O           | 8  |    |             |      | the 2810.         |
|   | FFICIAL_SIG |    |    | Format =    |      |                   |
|   | NATURE_DATE |    |    | YYYYMMDD    |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 5 | PERSONN     | T  | X  | Value =     | Requ | This is the       |
| 9 | EL_OFFICE\_ | ex | (2 | Personnel   | ired | surname of the    |
|   |             | t, | 5) | office      |      | personnel office  |
|   | CONTAC      | 25 |    | contact's   |      | contact. The      |
|   | T_LAST_NAME |    |    | last name   |      | contact must      |
|   |             |    |    |             |      | always have a     |
|   |             |    |    | Format =    |      | last name. If     |
|   |             |    |    | Left        |      | there is a case   |
|   |             |    |    | justify, no |      | of a contact      |
|   |             |    |    | p           |      | having only one   |
|   |             |    |    | unctuation, |      | name (e.g.,       |
|   |             |    |    | pad with    |      | Cher), then that  |
|   |             |    |    | trailing    |      | one name must be  |
|   |             |    |    | spaces      |      | 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.     |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | PERSONN     | T  | X  | Value =     | Con  | First name of the |
| 0 | EL_OFFICE\_ | ex | (1 | Personnel   | diti | personnel office  |
|   |             | t, | 7) | office      | onal | contact. This     |
|   | CONTACT     | 17 |    | contact's   |      | must be provided  |
|   | _FIRST_NAME |    |    | first name  |      | except in the     |
|   |             |    |    |             |      | rare circumstance |
|   |             |    |    | Format =    |      | that the contact  |
|   |             |    |    | Left        |      | only has one name |
|   |             |    |    | justify, no |      | (e.g., Cher).     |
|   |             |    |    | p           |      |                   |
|   |             |    |    | unctuation, |      |                   |
|   |             |    |    | pad with    |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | PERSONN     | T  | X( | Value =     | Con  | This is the       |
| 1 | EL_OFFICE\_ | ex | 1) | Personnel   | diti | middle initial of |
|   |             | t, |    | office      | onal | the personnel     |
|   | CONTACT_MID | 1  |    | contact's   |      | office contact.   |
|   | DLE_INITIAL |    |    | middle      |      | If the contact    |
|   |             |    |    | initial     |      | uses one name, or |
|   |             |    |    |             |      | if the contact    |
|   |             |    |    | Format = No |      | does not have a   |
|   |             |    |    | punctuation |      | middle name or    |
|   |             |    |    |             |      | initial, this     |
|   |             |    |    | Note = If   |      | field is blank.   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with a      |      |                   |
|   |             |    |    | space       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | PERSONN     | T  | X  | Value =     | Opti | This is the       |
| 2 | EL_OFFICE\_ | ex | (1 | Personnel   | onal | personnel office  |
|   |             | t, | 7) | office      |      | contact's         |
|   | CONTACT_    | 17 |    | contact's   |      | telephone number. |
|   | TELEPHONE\_ |    |    | daytime     |      |                   |
|   |             |    |    | area code   |      |                   |
|   | NUMBER      |    |    | and phone   |      |                   |
|   |             |    |    | number      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      |                   |
|   |             |    |    | dashes or   |      |                   |
|   |             |    |    | spaces, pad |      |                   |
|   |             |    |    | with        |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | 9127442286  |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | PA          | T  | X  | Value =     | Requ | This is the       |
| 3 | YROLL_OFFIC | ex | (2 | Payroll     | ired | surname of the    |
|   | E_CONTACT\_ | t, | 5) | office      |      | payroll office    |
|   |             | 25 |    | contact's   |      | contact. The      |
|   | LAST_NAME   |    |    | last name   |      | contact must      |
|   |             |    |    |             |      | always have a     |
|   |             |    |    | Format =    |      | last name. If     |
|   |             |    |    | Left        |      | there is a case   |
|   |             |    |    | justify, no |      | of a contact      |
|   |             |    |    | p           |      | having only one   |
|   |             |    |    | unctuation, |      | name (e.g.,       |
|   |             |    |    | pad with    |      | Cher), then that  |
|   |             |    |    | trailing    |      | one name must be  |
|   |             |    |    | spaces      |      | 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.     |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | PA          | T  | X  | Value =     | Con  | First name of the |
| 4 | YROLL_OFFIC | ex | (1 | Payroll     | diti | payroll office    |
|   | E_CONTACT\_ | t, | 7) | office      | onal | contact. This     |
|   |             | 17 |    | contact's   |      | must be provided  |
|   | FIRST_NAME  |    |    | first name  |      | except in the     |
|   |             |    |    |             |      | rare circumstance |
|   |             |    |    | Format =    |      | that the contact  |
|   |             |    |    | Left        |      | only has one name |
|   |             |    |    | justify, no |      | (e.g., Cher).     |
|   |             |    |    | p           |      |                   |
|   |             |    |    | unctuation, |      |                   |
|   |             |    |    | pad with    |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | PA          | T  | X( | Value =     | Con  | This is the       |
| 5 | YROLL_OFFIC | ex | 1) | Payroll     | diti | middle initial of |
|   | E_CONTACT\_ | t, |    | office      | onal | the payroll       |
|   |             | 1  |    | contact's   |      | office contact.   |
|   | MID         |    |    | middle      |      | If the contact    |
|   | DLE_INITIAL |    |    | initial     |      | uses one name, or |
|   |             |    |    |             |      | if the contact    |
|   |             |    |    | Format = No |      | does not have a   |
|   |             |    |    | punctuation |      | middle name or    |
|   |             |    |    |             |      | initial, this     |
|   |             |    |    | Note = If   |      | field is blank.   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with a      |      |                   |
|   |             |    |    | space       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | PA          | T  | X  | Value =     | Opti | This is the       |
| 6 | YROLL_OFFIC | ex | (1 | Payroll     | onal | payroll office    |
|   | E_CONTACT\_ | t, | 7) | office      |      | contact's         |
|   |             | 17 |    | contact's   |      | telephone number. |
|   | TELEP       |    |    | daytime     |      |                   |
|   | HONE_NUMBER |    |    | area code   |      |                   |
|   |             |    |    | and phone   |      |                   |
|   |             |    |    | number      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Format =    |      |                   |
|   |             |    |    | Left        |      |                   |
|   |             |    |    | justify, no |      |                   |
|   |             |    |    | dashes or   |      |                   |
|   |             |    |    | spaces, pad |      |                   |
|   |             |    |    | with        |      |                   |
|   |             |    |    | trailing    |      |                   |
|   |             |    |    | spaces      |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Example:    |      |                   |
|   |             |    |    | 9127442286  |      |                   |
|   |             |    |    |             |      |                   |
|   |             |    |    | Note = If   |      |                   |
|   |             |    |    | blank, pad  |      |                   |
|   |             |    |    | with spaces |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | REMARKS     | T  | X  | This is a   | Opti | There are no      |
| 7 |             | ex | (8 | free-form   | onal | restrictions or   |
|   |             | t, | 0) | field for   |      | requirements      |
|   |             | 80 |    | use when    |      | regarding the     |
|   |             |    |    | creating    |      | contents of this  |
|   |             |    |    | the         |      | field.            |
|   |             |    |    | corrective  |      |                   |
|   |             |    |    | action      |      |                   |
|   |             |    |    | file.       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | REMARKS     | T  | X  | This is a   | Opti | There are no      |
| 8 |             | ex | (8 | free-form   | onal | restrictions or   |
|   |             | t, | 0) | field for   |      | requirements      |
|   |             | 80 |    | use when    |      | regarding the     |
|   |             |    |    | creating    |      | contents of this  |
|   |             |    |    | the         |      | field.            |
|   |             |    |    | corrective  |      |                   |
|   |             |    |    | action      |      |                   |
|   |             |    |    | file.       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 6 | REMARKS     | T  | X  | This is a   | Opti | There are no      |
| 9 |             | ex | (8 | free-form   | onal | restrictions or   |
|   |             | t, | 0) | field for   |      | requirements      |
|   |             | 80 |    | use when    |      | regarding the     |
|   |             |    |    | creating    |      | contents of this  |
|   |             |    |    | the         |      | field.            |
|   |             |    |    | corrective  |      |                   |
|   |             |    |    | action      |      |                   |
|   |             |    |    | file.       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 7 | REMARKS     | T  | X  | This is a   | Opti | There are no      |
| 0 |             | ex | (8 | free-form   | onal | restrictions or   |
|   |             | t, | 0) | field for   |      | requirements      |
|   |             | 80 |    | use when    |      | regarding the     |
|   |             |    |    | creating    |      | contents of this  |
|   |             |    |    | the         |      | field.            |
|   |             |    |    | corrective  |      |                   |
|   |             |    |    | action      |      |                   |
|   |             |    |    | file.       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 7 | REMARKS     | T  | X  | This is a   | Opti | There are no      |
| 1 |             | ex | (8 | free-form   | onal | restrictions or   |
|   |             | t, | 0) | field for   |      | requirements      |
|   |             | 80 |    | use when    |      | regarding the     |
|   |             |    |    | creating    |      | contents of this  |
|   |             |    |    | the         |      | field.            |
|   |             |    |    | corrective  |      |                   |
|   |             |    |    | action      |      |                   |
|   |             |    |    | file.       |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 7 | FILLER      | T  | X  | Value = Pad | Requ | This field is     |
| 2 |             | ex | (1 | with spaces | ired | reserved for      |
|   |             | t, | 0) |             |      | future use.       |
|   |             | 10 |    |             |      |                   |
+---+-------------+----+----+-------------+------+-------------------+
| 7 | RE          | T  | X  | Value =     | Requ | The first 8       |
| 3 | PORT_NUMBER | ex | (1 | System      | ired | positions of this |
|   |             | t, | 5) | generated   |      | number are system |
|   |             | 15 |    | number      |      | generated and     |
|   |             |    |    |             |      | indicate the      |
|   |             |    |    | Format =    |      | quarter and year  |
|   |             |    |    | Left        |      | in which a record |
|   |             |    |    | justify,    |      | was transmitted   |
|   |             |    |    | pad with    |      | plus the optional |
|   |             |    |    | trailing    |      | 7-digit control   |
|   |             |    |    | spaces      |      | number. The user  |
|   |             |    |    |             |      | has the option of |
|   |             |    |    | Example:    |      | entering the      |
|   |             |    |    | NFC2        |      | number of his/her |
|   |             |    |    | 2002XXXXXXX |      | original report   |
|   |             |    |    | = second    |      | (notification to  |
|   |             |    |    | quarter in  |      | carrier, SF-2811, |
|   |             |    |    | the year    |      | etc.) in the      |
|   |             |    |    | 2002        |      | remaining 7       |
|   |             |    |    |             |      | spaces.           |
+---+-------------+----+----+-------------+------+-------------------+
| T |             | 13 | 13 |             |      |                   |
| O |             | 52 | 52 |             |      |                   |
| T |             |    |    |             |      |                   |
| A |             | B  | C  |             |      |                   |
| L |             | yt | ol |             |      |                   |
|   |             | es | um |             |      |                   |
|   |             |    | ns |             |      |                   |
+---+-------------+----+----+-------------+------+-------------------+