Form Approved

OMB No. 3206-0099

United States

Office of Personnel Management

Retirement Operations

Washington, DC 20415

Initial Certification of

Full-Time School Attendance

Reference

Date (mm/dd/yyyy)

Claim number (suffix)

CSF

Name of deceased employee

Name of child

Date of death (mm/dd/yyyy) On roll?

Yes No

•

The Application for Death Benefits shows that the child named

above, a survivor of a Federal employee or annuitant, is (or soon

will be) age 18. After reaching age 18, a child is eligible for a

survivor annuity only if unmarried and (1) a full-time student in an

accredited school or (2) incapacitated for self-support because

of a physical or mental disability that began before age 18.

If a child is unmarried and incapacitated for self-support because

of a mental or physical disability, do not fill in the other side of

this form. Instead, return the form to us with a doctor's certificate

describing the nature and extent of the child's disability. After we

review the documentation of the disability, we will write to you

about the child's eligibility for benefits.

If the child is unmarried and a full-time student, you should

complete Part A on the other side of this form; a school official

(the principal, administrator, registrar, etc.) should complete Part

B, and you should return the completed form to us promptly. If

the child's school year was not in session on the date of death

(shown above), have the school official complete Part B for the

last school year attended.

Send the completed form to:

U.S. Office of Personnel Management

Retirement Operations

1900 E Street, NW

Washington, DC 20415-3563

Privacy Act Statement

The Office of Personnel Management (OPM) administers the Civil Service Retirement System (Chapter 83, title 5, U.S. Code) and the Federal Employees

Retirement System (Chapter 84, title 5, U.S. Code). The information requested on the enclosed form is needed to document a retirement benefit or claim. 

The information may be shared and is subject to verification, via paper, electronic media, or through the use of computer 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 or continuation of benefits from OPM, 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. Executive Order 9397 (November 22, 1943)

authorizes the use of the Social Security Number. Providing the information is voluntary; however, failure to supply all the requested information may delay

or prevent action on the benefit or claim. Intentionally false statements and/or suspected illegal activities are reportable by us to the appropriate law

enforcement agencies.

Public Burden Statement

We estimate this form takes an average 90 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 or any other aspect of this form, including suggestions for reducing completion time,

to the Office of Personnel Management, Retirement and Benefits Publications Team (3206-0099), Washington, DC 20415-3430. The OMB Number

3206-0099 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

(THIS SPACE IS FOR THE USE OF THE OFFICE OF PERSONNEL MANAGEMENT ONLY.)

Remarks: Approved Not Approved Because Call up (M-Card) processed

Less than full-time school attendance

Not in school

Over 5-month break in attendance

Married

Non-recognized school

Other (specify)

Benefits specialist

Inspector Date (mm/dd/yyyy) Date (mm/dd/yyyy)

RI 25-41

Previous editions are not usable. Revised March 2010
Part A - To be completed by the payee (the person who expects to receive benefits for the student).

Read the reverse side of this form before answering the questions below; give full information; typewrite or print in ink.

1. Student's name (first, middle, last) 2. Student's date of birth (mm/dd/yyyy) 3. Student's Social Security Number 

4. Is the student married? Yes

No

If "Yes," show the date at right, sign item 7 of this part, and 

return this form. (It is not necessary to complete the rest of the 

form.)

Date of marriage (mm/dd/yyyy) 

Current 

Status 

5. Is the student enrolled in 

school on a full-time basis 

at the present time? 

Yes

No If "No," show the date the student last attended 

school on a full-time basis.

Last attended school (mm/dd/yyyy) 

Future 

Plans 

6. After the end of the school

year, does the student 

intend to continue as a 

full-time student with less 

than a 5-month break 

between school years? 

Yes

No

Undecided

If "Yes," give the details in items 6a and 6b.

} If "No" or "Undecided," go to item 7.

6a. Enter the date (or approximate 

date) the next school year or 

term begins after current 

enrollment (month, day, year).

6b. Complete name and mailing address (including ZIP code) of the educational institution the 

student will attend next year.

Payee 

Signs 

Here 

7. I certify that all information given in this certification is true and correct to the best of my knowledge and belief. I understand that 

I must immediately notify the Office of Personnel Management (OPM) if the student transfers to another school, discontinues 

school attendance, reduces attendance to less than full-time, marries, or dies. I further agree to return all overpayments of 

student benefits, including overpayments that may be erroneously made after I notify OPM of any terminating event. I authorize the 

 appropriate school official to verify the student's school attendance status to OPM in the manner requested by that agency.

Signature of payee Email address Daytime telephone number 

( ) 

Date (mm/dd/yyyy) 

Part B - To be completed by an official of the educational institution for the school year to . 

(month, year) (month, year) 

6. Show the total school hours per week:

4. Check the type of educational institution:

College or 

university

Vocational institute

Junior college/ 

community college

1. Is/was the student enrolled in and attending a

 full-time course of resident study or training

 (not correspondence) for the period requested?

3. Official ending date of the

 school year (mm/dd/yyyy)

2. Actual date the student started school for the

 school year indicated above (mm/dd/yyyy)

Yes No

High school

Trade school 

Technical institute

Other (specify)

5. Show the complete name and mailing address 

(including ZIP code) of the educational institution.

a. If college or equivalent, show credit hours

b. If high school or equivalent, show actual clock hours

c. If in a work-study program sponsored by the school,

show hours at work

hours at school

Complete items 7 and 8 below if your institution is not a state college, state university, or public high school.

7. Show the complete name and address (including ZIP code) of the 

organization which accredits, licenses, or otherwise recognizes the school.

8. If the educational institution is licensed, show:

a. Current license number: b. Expiration date of current license 

(mm/dd/yyyy)

School 

Official 

Signs 

Here

I certify that the information given in regard to requested school enrollment of the 

above-named student is true and correct to the best of my knowledge and belief.

Signature of principal, administrator, registrar, etc. Telephone number 

Warning: Any intentionally false statement, willful 

concealment of material fact, or use of a writing or 

document knowing the same to contain a false, 

fictitious, or fraudulent statement or entry, is a violation 

of the law punishable by a fine of not more than $10,000 

or imprisonment of not more than 5 years, or both. (18 

U.S.C. 1001)

Title Date (mm/dd/yyyy)

( ) 

Reverse of RI 25-41 

Revised March 2010