OMB Approval 3206-0173

— Designation of Beneficiary _
csrs Civil Service and Federal Employees Retirement Systems FERS
SEE SeS Symon Important: Read all instructions before filing this form. Fetromen yom

A. Identification
Name (last, first, middle)

Date of birth (mm/dd/yyyy) | Social security number

Place an "X" in the An employee Retired or an

appropriate box: =}

applicant for retirement

Tf you are retired, give your claim
number

CSA

Former employee eligible
for retirement in the future

Department or agency in which presently employed (or former department or agency):
Department or agency

Location (city, state and ZIP code)

Name of your retirement system

CSRS [_]rers

Civil Service Retirement System (CSRS)

I, the individual identified above, designate the beneficiary or beneficiaries named
below to receive any lump-sum benefit which may become payable under CSRS after
my death. I understand that this designation of beneficiary will not affect the rights of
any survivors who may qualify for annuity benefits after my death, cancels any
previous designation of beneficiary, and remains in effect until I cancel it in writing by
filing a new designation form.

I direct, unless otherwise indicated below, that if more than one beneficiary is named,
the share of any beneficiary who may predecease me or who may be disqualified for
any other reason, shall be distributed equally among the stated beneficiaries, or entirely
to the survivor. If none of the beneficiaries are alive and eligible to receive payment
when a lump-sum payment becomes payable, this designation is void, and payment
will be made according to the order of precedence set by law.

Properly completed designations for CSRS employees and retirees are not valid unless
the Office of Personnel Management (OPM) receives the form before the death of the
designator. Mail both the completed Original and Employee copies of the SF 3102 to
OPM, P.O. Box 45, Boyers, PA 16017.

For current CSRS employees, OPM will validate both completed copies of the form
and send you a copy for your records. Your employing agency does not maintain this
form.

Federal Employee Retirement System (FERS)

I, the individual identified above, designate the beneficiary or beneficiaries named
below to receive any lump-sum benefit which may become payable under FERS after
my death, including lump-sum death benefits which may become payable based on
amounts contributed to CSRS before I became covered by FERS. | understand that
this designation of beneficiary cancels any previous FERS or CSRS designation of
beneficiary, and that it remains in effect until I cancel it in writing by filing a new
designation form or I receive payment of my FERS retirement contributions.

I direct, unless otherwise indicated below, that if more than one beneficiary is named,
the share of any beneficiary who may predecease me or who may be disqualified for
any other reason, shall be distributed equally among the stated beneficiaries, or entirely
to the survivor. If none of the beneficiaries are alive and eligible to receive payment
when a lump-sum payment becomes payable, this designation is void, and payment
will be made according to the order of precedence set by law.

Properly completed designations for FERS employees are not valid unless the
employing agency receives them before the death of the designator. FERS retirees
must send the designation form to OPM, P.O. Box 45, Boyers, PA 16017 before the
death of the designator for this form to be valid.

For current FERS employees, the agency will keep the original copy in your Official
Personnel Folder and send it to OPM afier you separate from Federal service.

B. Information Concerning Beneficiaries (See Examples on the Reverse of Part 1. Type or print clearly)

First name, middle initial, and last
name of each beneficiary*

Address (including ZIP code) of each
benefi¢iary**

Share to be paid to

Relationship to
each beneficiary

you*

Date of designation (mm/dd/yy) Your signature

Total = 100%

C. Witness (A witness is not eligible to receive a payment as a beneficiary):

We, the undersigned, certify that this statement was signed in our presence.

Signature of witness Address (including ZIP code)

Signature of witness Address (including ZIP code)

Receiving Agency Certification: I have reviewed this designation and certify that the designated shares total 100% and that the witness was not designated as a beneficiary.
Date (mm/dd/yyyy)

Date received by agency (mm/dd/yy

| Signature

* We will pay to the person you designate, even if that person's name or relationship to you changes after you file this designation. For example, suppose you designate your spouse and then you
divorce and you marry someone else. We will pay any lump sum to your former spouse unless you submit another designation to cancel prior designations or to designate who we are to pay.

** We will write to the address you provide here to contact the person you designate. However, that person is obligated to contact us after your death to apply for any death benefits that may be payable.

Type or print your return address so that we can return a copy to you.
T 7 See back of Employee Copy for instructions on
where to file this form. (Retain until the FERS
employee leaves Federal service and then send to

the Office of Personnel Management.)

For current CSRS employees - - both copies must be
sent to OPM.

Part 1 - Original Copy
This revision combines and supersedes all prior versions of SF 2808 and SF 3102

Standard Form 3102

S. Office of Personnel Management
Revised October 2022

U:
5 CFR 843.205


Important - The filing of this form will completely cancel any Designation of Beneficiary under CSRS or under FERS you have previously filed. Be sure to
name in this form all persons you wish to designate as beneficiaries of any lump sum payable at your death.

1. How to Designate One Beneficiary

Examples of Designations

Do not write names as M.E. Brown or as Mrs. John H. Brown. If you want to designate your estate as

beneficiary, enter "My estate" in the beneficiary column.

First name, middle initial, and last Address (including ZIP code) of each Relationship to Share to be paid to
name of each beneficiary* beneficiary** you* cach beneficiary
Mary E. Brown 214 Central Avenue Niece 100%

Muncie, IN 47303

2. How to Designate More Than One Beneficiary

Be sure that the shares to be paid to the several beneficiaries add up to 100 percent.

First name, middle initial, and last
name of each beneficiary*

Address (including ZIP code) of each
beneficiary**

Share to be paid to

Relationship to
you* cach beneficiary

Alice M. Long

509
Red

Canal Street
Bank, NO

07702

Aunt 25%

360 Williams Street
Joseph P. Brady Red Bank, NI 07701 Domestic Partner 25%
792 Broadway
Catherine L. Rowe Whiting, IN 46394 Mother 50%

3. How to Designate A Contingent Beneficiary

First name, middle initial, and last
name of each beneficiary*

Address (including ZIP code) of each
beneficiary**

Relationship to
you*

Share to be paid to
each beneficiary

John M. Parrish,

Otherwise to: Susan A Parrish

4. How to Designate An Inter Vivos Trust

810 West 180th Street
New York, NY 10033

810 West 180th Street

New York, NY 10033

(A trust that you set up during your lifetime)

Father 100%

Sister 100%

First name, middle initial, and last

Address (including ZIP code) of each

Relationship to Share to be paid to

name of each beneficiary* beneficiary** you* cach beneficiary
Trustee(s) or Successor
Trustee(s) as provided in the Trustee 100%

John Q. Public Trust Agreement dated
if valid. Otherwise to:

12/18/2016,

Mary E. Brown

5, How to Designate A Testamentary Trust

214 Central Avenue
Muncie, IN 47303

(A trust that is set up when you die, according to terms in your will)

Niece

First name, middle initial, and last
‘name of each beneficiary*

‘Address (including ZIP code) of each
beneficiary**

Relationship to
you*

Share to be paid to
cach beneficiary

Trustee(s) or Successor
Trustee(s) as provided in my

Last Will and Testament, if valid
Otherwise to:

Trustee 100%

Maria Sufuentes

6. How to Cancel a Designation of Beneficiary and Effect Payment Under Order of Precedence

5909 Pacific Avenue,

NW

Washington, DC 20019

(See back of employee copy)

Niece 100%

First name, middle initial, and last
name of each beneficiary*

‘Address (including ZIP code) of each
beneficiary**

Relationship to
you*

Share to be paid to
cach beneficiary

cancel prior designations

Standard Form 3102 (Reverse of Part 1)
Revised October 2022


Instructions
Do Not Fill Out This Form Until You Have Read The Information and Instructions Below

This Designation of Beneficiary Form is used to designate who is to receive a lump-sum payment which may become payable under CSRS or FERS.
It does not affect the right of any person who is eligible for survivor benefits. This form may not be used and will not be effective in any way to elect,
or demonstrate the intent to elect, a survivor annuity for a spouse, former spouse, or an individual who has an insurable interest in an employee.

Do not confuse this form with designation forms used for other types of benefits: Standard Form 2823, Designation of Benefi
Group Life Insurance Program; TSP-3, Thrift Savings Plan Designation of Beneficiar

Compensation of Deceased Civilian Employee.

This form is for employees and retirees under CSRS and FERS

Order of Precedence

You do not need to make a designation if you are satisfied with the order of
precedence that the law provides. That order of precedence follows:

1. To your widow or widower.

2. If your widow(er) is deceased, to your child or children, with the share
of any deceased child distributed among the descendants of that child.

3. Ifnone of the above, to your parents in equal shares or the entire amount
to the surviving parent.

4. Ifnone of the above, to the executor or administrator of your estate.

5. Ifnone of the above, to your other next of kin under the laws of the State
in which you live at the time of your death.

6. Payment of a lump sum will be made to the first person or persons listed
above who are alive on the day you die.

Designating a Beneficiary

1. You can designate any person, firm, corporation, trust, or legal entity as
your beneficiary.

If you want to designate a trust, see examples 4 and 5 on the back of
Part 1. Those examples name a contingent beneficiary in case the trust
is not valid. You don't have to name a contingent beneficiary unless
you want to, If the trust is not valid, and you do not name a contingent
beneficiary, OPM will pay according to the order listed under

"Order of Precedence" above.

iary - Federal Employees"
or Standard Form 1152, Designation of Beneficiary - Unpaid

6. You cannot change or cancel a designation of beneficiary in a last will
or testament unless it is signed, witnessed, and filed as described in
paragraph 3.

7. A designation of beneficiary remains in effect until (1) you cancel it by
filing a new designation, or (2) you receive a refund of your retirement
deductions before retirement. To inform us if the name or address of a
beneficiary changes, file a new designation of beneficiary. It may be
important to file a new designation if your family situation changes.

Completing the Designation Form

1. The examples printed on the back of the first page of this form may be
helpful to you in naming a beneficiary or canceling a prior designation
of beneficiary.

2. If you designate more than one beneficiary, be sure that the shares to be
paid to them add up to 100 percent. Do not use dollar amounts to
indicate the shares.

3. If you wish to designate more than three persons in Part B, use a blank
sheet of paper which you will attach to the form. Print your name and
date of birth at the top of the attachment and provide the information
required in Part B for each beneficiary. Your signatures on the form and
on the attachment must be witnessed by the same person. The witness
must sign both the form and the attachment.

4, Complete the form in duplicate. Type or print all entries except
signatures. Do not use pencil.

5. Do not erase or alter entries. No Corrections are permitted on this form.

2. You can change your beneficiary at any time, without the knowledge or

consent ofa previous beneficiary, and this right cannot be waived or Where to Submit the Completed Form
For separated CSRS or FERS employees, retirees and individuals
receiving recurring benefits from OWCP: If you have left Federal
employment, if you are receiving recurring benefits from OWCP, or if you
have retired, file this form with OPM, Retirement Operations Center, P.O.
Box 45, Boyers, PA 16017-0045.

Your designation will not be effective until the date it is received by your
employing agency (or OPM if you are not employed). The employee copy of
this form will be noted and returned to you as evidence that the original has
been received and filed. Please keep the duplicate in a safe place along with
your other important papers.

3. A designation of beneficiary must be in writing, signed, and witnessed.
If you are an employee, the designation must be received in your
employing office prior to your death, If you are a separated employee, a
retiree or a person receiving recurring payments from the Office of
Workers’ Compensation Programs (OWCP), the designation must be
received by OPM prior to your death.

4. A witness to a designation of beneficiary is ineligible to receive
payment as a beneficiary.

5. The person(s) named will be considered a beneficiary (beneficiaries) for

both CSRS and FERS lump-sum benefits. For the employing agency of current FERS employees: File the Official

Personnel Folder (OPF) copy on the right side of the OPF. If the FERS
employee leaves Federal service, send all designations of beneficiary in the
OPF to OPM. For current CSRS employees, both copies of the form must be
mailed to OPM because the employing agency does not maintain copies in
the OPF.

Privacy Act Statement
Pursuant to 5 U.S.C. 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to collect
the information requested on this form by 5 U.S.C. chapter 83, subchapter III (Civil Service Retirement) and 5 U.S.C. chapter 84, subchapter IV (Federal Employee's Retirement).
OPM is authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008).
Purpose: OPM is requesting this information to determine who will receive a lump sum benefit in the event of your death. Routine Uses: The information requested on this form
may be shared externally as a "routine use” to other Federal agencies and third-parties when it is necessary to to process your designation. For example, matching programs, with
national, state, local or other charitable or social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for
determination of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they
are investigating a violation or potential violation of civil or criminal law. Consequences of Failure To Provide Information: Providing this information to OPM is voluntary.
However, failure to provide this information may delay or prevent OPM from processing the designation of beneficiary as requested by the applicant.

Public Burden Statement

We estimate providing this information takes an average of 15 minutes per response to complete, including the time for reviewing instructions, getting the needed data, and
reviewing the completed form. Send comments regarding our estimate including suggestions for reducing completion time, to the U.S. Office of Personnel Management (OPM).
Retirement Services Publications Team (3206-0173), Washington, D.C. 20415-0001. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.

Standard Form 3102 (Reverse of Part 2)
Revised October 2022