Federal Employees
 

Retirement System
 

 - 

	 

	 

	 

 - 

	 

	 

	 

	 

 

CSRS/FERS Handbook for Personnel and Payroll Offices 

NSN 7540-01-255-3670 

3107-106 

Application for Immediate Retirement 

Federal Employees Retirement System 

Standard Form 3107 

Previous editions are not usable. Revised June 2006 

This application is for you if you are a Federal employee covered by the Federal Employees Retirement System (FERS) and you wish 

to apply for retirement with an immediate annuity. You should use this application if you want to apply for an annuity which will 

begin within 30 days of your separation from Federal service. 

Do not use this application to apply for a deferred annuity. A deferred annuity begins more than 30 days after the date of final 

separation. If you want to apply for a deferred annuity, call the Office of Personnel Management (OPM) on 1-888-767-6738 

(TTY: 1-800-878-5707) to request an RI 92-19, FERS Application for Deferred or Postponed Retirement. If you prefer, you can 

write to us at Office of Personnel Management, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045, or 

email us at retire@opm.gov.

You should have received an informational pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees 

Retirement System, with this application. If you did not receive the pamphlet you should get a copy from your employing agency or 

from our website at www.opm.gov.

Retirement benefits and retirement processing are complicated. Read the information in the pamphlet carefully. When you decide to 

retire, give your agency advance notice so it can be sure your records are complete and it can carry out its responsibilities in 

processing the paperwork associated with your retirement. 

Give your completed application to the personnel office of your employing agency. They will forward your application to your 

agency payroll office and then to the Office of Personnel Management for processing. If you have any questions, ask your employing 

office for assistance. You must apply separately for any benefits payable from the Thrift Savings Plan and the Social Security 

Administration. 

If your address changes after your application has been forwarded to the Office of Personnel Management, call us on 1-888-767-6738 

(TTY: 1-800-878-5707). If you prefer, you can write to us at the address above. If you have received your claim number, please refer 

to it. If you have not received your claim number we'll need your name, date of birth and Social Security Number. 

Instructions for Completing Application 

Type or print clearly. If you need more space in any section, use 

a plain piece of paper with your name, date of birth, and Social 

Security Number written at the top. If you do not know an 

answer write "unknown." If you are unsure of information (for 

example, if you do not know an exact date), answer to the best 

of your ability, followed by a question mark (?). 

The following additional information should help you to answer

those questions on the application which are not entirely

self-explanatory. 

Section A Identifying Information

Item 2: List other names under which you have been employed

in the Federal government (such as a maiden name).

This will help us to locate and identify records 

maintained under these names.

Item 3: Enter the address to which correspondence should be 

mailed. If you want your payments sent to a bank, do

not enter the bank address here; see Section H of the

application form.

Item 4: Give a telephone number where you can be reached

after you retire and the best time to reach you during

business hours.

Section B Federal Service

Item 2: Enter the date of final separation for retirement.

(Leave blank if applying for disability retirement

and not separated.)

Item 4: Indicate whether or not you have performed active duty 

that terminated under honorable conditions in the 

armed services or other uniformed services of the 

United States including the following:

a. Army, Navy, Marine Corps, Air Force or Coast 

Guard of United States;

b. Commissioned Corps of the Public Health Service

after June 30, 1960;

c. Commissioned Corps of the National Oceanic and

Atmospheric Administration (formerly Coast and

Geodetic Survey and Environmental Science

Services Administration) after June 30, 1961;

d. Cadet or Midshipman of the U.S. Military

Academy, U.S. Air Force Academy, U.S. Coast 

Guard Academy, or U.S. Naval Academy.

Service in reserve components and/or the National

Guard is not considered active Federal military

service except when ordered to active duty in the 

service of the United States and during an initial

4-month training period for Guardsmen. However,

full time National Guard duty (as such term is

defined in Section 101(d) of title 10) is creditable, 

if such service interrupts FERS creditable civilian

service and is followed by reemployment, in 

accordance with Chapter 43 of title 38, that occurs

after August 1, 1990.
	 

	 

 - 

	 

 - 

	 

Standard Form 3107 

2 Revised June 2006 

If you have performed such service, complete and 

attach Schedule A, furnishing the requested information 

for each period of active duty. 

To receive FERS credit for military service performed 

on or after January 1, 1957, you must pay a deposit. 

The amount of the deposit is:

 For service performed through 12/31/98 

(3% of your military basic pay). 

	 For service performed from 1/1/99 through 

12/31/99 (3.25% of your military basic pay). 

	 For service performed from 1/1/00 through 

12/31/00 (3.4% of your military basic pay). 

	 For service performed from 1/1/01 to the present 

(3% of your military basic pay). 

You must pay the deposit to your agency while you are 

still employed. You may not pay OPM after you retire. 

If you are entitled to have part of your retirement 

computed under CSRS rules, military service 

performed prior to your transfer to FERS comes 

under CSRS deposit rules. These rules are as follows: 

	 The CSRS deposit is 7 percent of your military 

basic pay. 

	 If you were first employed in a civilian position 

before October 1, 1982, you do not pay the 

deposit and you are eligible for a Social Security 

benefit at age 62, the CSRS part of your annuity 

will be recomputed at age 62 to delete credit for 

the post-1956 military service. 

	 If you were first hired on or after October 1,

1982, you will not receive any credit for 

post-1956 military service if you do not make 

the deposit for it. 

	 CSRS military service deposits must also be paid 

to your agency while you are still employed. 

Item 5: If you are receiving, or have applied for, military retired 

pay or benefits from the Department of Veterans Affairs 

in lieu of military retired pay, answer "yes" to Item 5, 

then complete and attach Schedule B-Military Retired 

Pay. (Note: Military retired pay includes disability 

pay.)

This information is needed to assure correct credit for 

military service. Receipt of military retired pay may 

affect the computation of your annuity rate. 

If you are waiving military retired pay awarded for: 

	 reserve service under Chapter 1223, title 10,

U.S. Code (formerly Chapter 67, title 10); or

	 a disability incurred in enemy combat or 

caused by an instrumentality of war in the line 

of duty during a period of war as defined in 

Chapter II, title 38, U.S. Code, 

attach a copy of the notice of the award to this 

application. 

If you do not have this documentation, you can request

verification of the type of award from: 

For Army, Navy, Air Force, and Marine Corps

retired pay verifications:

DFAS 

U.S. Military Retirement Pay 

P.O. Box 7130

London, KY 40742-7130. 

For Coast Guard retired pay verification: 

Commanding Officer (RAS) 

USCG Pay and Personnel Center 

444 SE Quincy Street 

Topeka, KS 66683-3591. 

If you are waiving military retired pay for FERS 

retirement purposes, your agency can help you 

prepare your request for waiver. Attaching a copy 

of your waiver request and the finance center's 

acknowledgment (if available) to your application

may help us to process your claim more quickly. 

(Even if you have already waived your military 

retired pay to receive benefits from the 

Department of Veterans Affairs, you also need to 

file a waiver for FERS.) 

Section C Marital Information

Item 2: Indicate whether you have a living former spouse 

to whom a court order awards a survivor annuity 

based on your Federal employment. If you answer 

"yes," you must submit a certified copy of the 

court order and any attachments or amendments. 

You are not required to submit this if you are sure 

the court order has already been submitted.

Section D Annuity Election

(See pages 13-20 of SF 3113, Applying for Immediate 

Retirement Under the Federal Employees Retirement 

System.) 

Read the information about survivor benefits found in the 

pamphlet, Applying for Immediate Retirement Under 

FERS, before completing Section D. 

Survivor elections terminate upon the death of the person 

elected, divorce of the annuitant from the elected spouse

before age 55 [unless the parties were married for 30 years 

or more], or subject to the terms of a court order acceptable 

for processing. You must notify us when one of these 

events occurs. Please note that, in accordance with the law, 

both a survivor annuity election made at retirement and a 

pre-divorce survivor annuity election terminate upon

death or divorce and the annuitant must make a new 

election (reelection) within 2 years after the terminating

event to provide a survivor annuity for a spouse acquired 

after retirement or for a former spouse. Continuing a 

survivor reduction, by itself, is not effective to reelect a 

survivor annuity for a spouse married after retirement or 

for a former spouse. 

Box 4: If you initial Box 4, a person selected by you, 

who has an insurable interest in you, will receive 

a survivor annuity upon your death. Insurable 

interest exists if the person named may reasonably 

expect to derive financial benefit from your 

continued life. A disabled child or a former 

spouse are persons who might have an insurable 

interest in you.

 

 - 
 

 - 


 


 . 

	 

	 

	 

	 

Standard Form 3107 

3 Revised June 2006 

If you choose an insurable interest survivor

annuity, the survivor annuity will be 55 percent of

your annuity after your annuity has been reduced

to provide this benefit. The table below shows the

reduction percentages.

Any employee who is not retiring for disability

and who can prove good health may elect a

reduced annuity to provide a survivor annuity for

a person having an insurable interest in the
 

retiree.

You may elect this insurable interest survivor annuity

in addition to a regular survivor annuity for a current or

former spouse. If you elect an insurable interest annuity

for your current spouse, you must both jointly waive

the current spouse annuity. Generally, an insurable

interest annuity cannot be cancelled. However, if you 

elect the insurable interest annuity for a current spouse

because a court order awards (or you have elected) the

regular survivor annuity to a former spouse, the

insurable interest election for your current spouse can
 

be converted to a current spouse annuity if the former
 spouse loses entitlement to the regular annuity.

If you choose an insurable interest annuity, the amount 

of the reduction in your annuity will depend upon the 

difference between your age and the age of the person 

named as survivor annuitant, as shown in the table

below.

Age of the Person Named

in Relation to That of

Retiring Employee

Reduction

in Annuity

of Retiring 

Employee

Older, same age, or less than 5 years younger 10%

5 but less than 10 years younger 15%

10 but less than 15 years younger 20%

15 but less than 20 years younger 25%

20 but less than 25 years younger 30%

25 but less than 30 years younger 35%

30 or more years younger 40%

Box 5: If you initial box 5, your former spouse(s) will receive a 

survivor annuity upon your death. The maximum 

survivor annuity payable to your former spouse(s) is 

50% of your unreduced annuity. Your annuity will be 

reduced 5% or 10% according to the total benefit you

want to provide.

You may elect to provide a survivor annuity for more 

than one former spouse. The total of the survivor 

annuities must equal either 25% or 50% of your 

unreduced annuity.

If you are married, you must have your spouse's consent

to choose this option, because any benefit elected for a 

former spouse limits what can be elected for your

current spouse. (Complete and attach SF 3107-2,

Spouse's Consent to Survivor Election, to your 

application.) The maximum combined survivor benefits

that can be elected for your current and former spouse(s)

is 50% of your benefit.

Section E Insurance Information

Item 1b: Indicate whether there is a court order or administrative

order currently in effect that requires you to provide

health benefits coverage for your child(ren). If you

answer "yes," you must submit a copy of the court

order or administrative order.

Section F Other Claim Information

Item 1: If you have applied for, or received, workers' compensation from the Office of Workers' Compensation 

Programs, U.S. Department of Labor, because of a 

job-related illness or injury, check the "yes" box and 

complete Schedule C

In Schedule C you should provide the following 

information: 

1. If you are receiving (or have received in the last 2 

years) compensation, enter your compensation 

claim number(s), the beginning and ending dates of 

each period for which compensation was paid, and 

whether the benefits were a scheduled award or 

disability compensation. 

2. If you have applied for, but are not receiving 

benefits, indicate whether your claim is pending 

or has been denied and the claim numbers 

applicable.

3. Indicate whether you agree to notify us if the

status of your workers' compensation claim 

changes and whether or not you authorize the

Office of Personnel Management and/or the 

Office of Workers' Compensation Programs to 

collect any overpayment if we find that you 

were paid, but not eligible for, both compensation 

and annuity benefits covering the same period of 

time. Without this authorization from you, we 

will not pay your annuity until we can confirm 

that OWCP is not paying you compensation.

The information requested regarding benefits from 

the Office of Workers' Compensation Programs is

needed because the law prohibits the dual compensation which would exist if you received both a 

FERS annuity and compensation for total or partial 

disability under the Federal Employees' Compensation Act. 
 - - 

Standard Form 3107 

4 Revised June 2006 

Section G Information About Children

Complete Section G by providing the names and dates of birth 

of your unmarried dependent children under the age of 18. Also 

list any child who is over age 18 and incapable of self-support 

because of mental or physical disability incurred before age 18. 

Check the box headed "disabled" by the name of each child to 

whom this applies. Information about your children in your 

annuity claim file may help to expedite the processing of claims 

for survivor benefits in the event of your death.

Section I Applicant's Certification

Be sure to sign (do not print) and date your application after

reviewing the warning. 

Privacy Act Statement

Solicitation of this information is authorized by the Federal Employees Retirement law, (Chapter 84, title 5, U.S. Code), the Federal Employees' Group Life Insurance 

law (Chapter 87, title 5, U.S. Code) and the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code). The information you furnish will be used to 

identify records properly associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future 

benefits, and to maintain a unique identifiable claim file. 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 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. Executive Order 

9397 (November 22, 1943) authorizes use of the Social Security Number. The Government may use your number in collecting and reporting amounts that you owe 

the Government. Failure to furnish the requested information may delay or prevent action on your application. Information you provide about your unmarried 

dependent children may be used to expedite their claims after you die; however, your failure to supply such information will not affect any future rights they may 

have to benefits. 
Federal Employees 

Retirement System 

 - 

	 	 

	 	 

	 

	 

	 

	 	 

	 

	 

	 

- 

-

-

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 Standard Form 3107 

NSN 7540-01-255-3670 Previous editions are not usable. Revised June 2006 

Federal Employees Retirement System

Application for Immediate Retirement

See Privacy Act

Information on

Instruction Sheet

Section A Identifying Information

1. Name (last, first, middle) 2. List all other names you have used

3. Address (number, street, city, state, ZIP code) 4a. Daytime telephone # after retirement (including area

code)

4b. Best time to reach you

4c. Email address 4d. FAX number

5. Date of birth (mm/dd/yyyy) 6. Social Security Number

7. Are you a citizen of the United States of America?

Yes No

8. Is this an application for disability retirement?

Yes (Ask your employing office about other documents you must submit) No

Section B Federal Service 

1. Department or agency from which you are retiring (include bureau or division, address and ZIP code) 2. Date of final separation (mm/dd/yyyy)

3. Title of position from which you are

retiring

4. Have you performed active honorable service in the Armed Forces or other uniformed services of the United States (see instructions for definitions)? 

Yes (Complete Schedule A and attach it to this form) No

5. Are you receiving or have you applied for military retired pay? (Note: If you later become entitled to military retired pay you must notify OPM.)

Yes (Complete Schedule B and attach it to this form) No

Section C Marital Information (All applicants must complete questions 1 and 2 below.) 

1. Are you married now? (A marriage exists until ended by death, divorce, or annulment.) 

Yes (Complete items 1a - 1f) No (Go to item 2)

1a. Spouse's name (last, first, middle) 1b. Spouse's date of birth (mm/dd/yyyy) 1c. Spouse's Social Security Number

1d. Place of marriage (city, state) 1e. Date of marriage (mm/dd/yyyy) 1f. Marriage performed by: Clergyman or Justice of Peace

Other (explain):

2. Do you have a living former spouse(s) to whom a court order gives a survivor annuity? 

Yes (Attach a certified copy of the court order[s] and any amendments.) No

Section D Annuity Election

Make your election by initialing the box beside the type of annuity you want to receive and give any other information requested. Read the pamphlet SF 3113, 

Applying for Immediate Retirement under FERS, and the explanations below and consider your election carefully. No change will be permitted after your 

annuity is granted except as explained in the pamphlet. If you are married at retirement, the law provides an annuity with full survivor benefits for your spouse 

unless your spouse consents to your election not to provide maximum survivor benefits. 

Your election to provide a survivor annuity for a current spouse terminates upon the death of that spouse or if the marriage ends due to divorce or annulment. 

You are required to make a new election (reelect) within 2 years of the terminating event if you wish to reelect a former spouse or within 2 years of a 

post-retirement marriage to elect a post-retirement spouse. 

1. I choose a reduced annuity with maximum survivor annuity for my spouse named in Section C. If you are married at retirement, 

you will receive this type of annuity unless your spouse consents to your election not to provide maximum survivor benefits. If you 

receive this annuity, your annuity will be reduced by 10%. Your spouse's annuity upon your death will be 50% of your unreduced 

annuity. 

Initials

2. I choose a reduced annuity with a partial survivor annuity for my spouse named in Section C. If you choose this option, your 

annuity will be reduced by 5%. Upon your death, your spouse's annuity will be 25% of your unreduced annuity. You must have 

your spouse's consent to choose this option. Complete form SF 3107-2, Spouse's Consent to Survivor Election, and attach it to your 

application.

Initials

3. I choose an annuity payable only during my lifetime. If you are married at retirement, you cannot choose this type of annuity 

without your spouse's consent. No survivor annuity will be paid to your spouse after your death if he or she consents to this 

election and any health benefits will cease. In addition, your spouse will not be eligible to enroll in the Federal Long Term Care 

Insurance Program, if he/she is not enrolled at the time of your death. If you are married and elect this, complete form SF 3107-2, 

Spouse's Consent to Survivor Election, and attach it to your application.

Initials 
 _______________

 _______________

 _______________%

-



-

-

() () 

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 Standard Form 3107 

NSN 7540-01-255-3670 Previous editions are not usable. Revised June 2006 

4. I choose a reduced annuity with survivor annuity for the person named below who has an insurable interest in me. You must be 

healthy and willing to provide medical evidence if you choose this type of annuity. (Disability annuitants are not eligible to choose 

this type of annuity.) 

Initials 

Name of person with insurable interest Relationship to you Date of birth (mm/dd/yyyy) Social Security Number

5. I choose a reduced annuity with survivor annuity for my former spouse(s) as follows: You must attach: (1) Copies of divorce 

decrees for all former spouses for whom you elect to provide a survivor annuity. (2) If you are married, attach a completed 

SF 3107-2, Spouse's Consent to Survivor Election. You cannot choose this option and provide a maximum survivor annuity for 

your spouse (Box 1). Your election to provide a survivor annuity for a former spouse terminates upon the death of that spouse or the 

remarriage of your former spouse before age 55. 

Initials

Name and address of former spouse Date of marriage

(mm/dd/yyyy)

Date of divorce

(mm/dd/yyyy)

Date of birth

(mm/dd/yyyy)

Social Security Number

Survivor annuity equal

to %

of my annuity

Name and address of former spouse Date of marriage

(mm/dd/yyyy)

Date of divorce

(mm/dd/yyyy)

Date of birth

(mm/dd/yyyy)

Social Security Number

Survivor annuity equal

to %

of my annuity

Total (either 25% or 50% of your unreduced annuity)

Section E Insurance Information See the pamphlet SF 3113, Applying for Immediate Retirement Under the Federal Employees Retirement System,

for information.

1a. Are you eligible to continue Federal Employees Health Benefits coverage as a 

retiree?

Yes No

1b. Is there a court order or administrative order currently in effect that requires 

you to provide health benefits coverage for your child(ren)?

Yes (Attach a copy of the court/administrative order) No

2. Are you eligible to continue Federal Employee's Group Life Insurance coverage as a retiree? 

Yes No

3. Are you currently enrolled in the Federal Long Term Care Insurance Program (FLTCIP)?

Yes You will automatically continue your coverage into retirement, as long as you continue to pay applicable premiums. If you are currently 

paying FLTCIP premiums by agency payroll deduction, you must arrange to pay premiums another way, either by deductions from your 

annuity, through automatic bank debit or direct bill. Please call LTC Partners at 1-800-LTC-FEDS (1-800-582-3337) to make these 

arrangements. 

No

Section F Other Claim Information

1. Are you receiving or have you applied for (or received within the past 2 years) workers' compensation from the Department of Labor because of a job-related illness or injury?

Yes (Complete Schedule C and attach it to this form) No

2. Have you previously filed any application under the Civil Service Retirement System or Federal Employees Retirement System (for retirement, refund, deposit or redeposit, 

or voluntary contributions)? 

Yes (Complete items 2a and 2b below.) No 

2a. Type of application Refund Deposit or redeposit

Retirement Return of excess deductions Voluntary contributions 

2b. Claim number(s)

Section G (Optional) Information About Your Unmarried Dependent Children

1. Dependent child's name

(first, middle, last) 

2. Date of birth

(mm/dd/yyyy)

3.Disabled 1. Dependent child's name

(first, middle, last)

2. Date of birth

(mm/dd/yyyy)

3.Disabled
-


 

-

-

-

-

-

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 Standard Form 3107 

NSN 7540-01-255-3670 Previous editions are not usable. Revised June 2006 

Section H Direct Deposit and Tax Withholding Information

1.

Public Law 104-134 requires that most Federal payments be paid by Direct Deposit through Electronic Funds Transfer (EFT) into a savings or checking 

account at a financial institution. However, if receiving your payment electronically would cause you a financial hardship, or a hardship because you 

have a disability, or because of a geographic, language or literacy barrier, you may invoke your legal right to a waiver of the Direct Deposit requirement, 

and continue to receive your payment by check.

1a. Select one of the following: 

Please send my annuity payments directly to my checking or savings account. (Go to item 2)

Receiving my payment(s) electronically would cause me a financial hardship, or a hardship because of a disability, or because of a geographic, 

language or literacy barrier. I hereby invoke my legal right to a waiver of the Direct Deposit requirements of Public Law 104-134. Please send
 

my payment(s) by check. (Go to item 4)

My permanent payment address is outside the United States in a country not accessible via direct deposit. (Go to item 4)

2. Financial Institution Routing Number You may obtain this number by calling your bank, credit union, or savings institution.

This number is very important. We cannot pay by direct deposit without it.

3. Checking or Savings Account Number 3a. What kind of account is this?

Checking Savings

3b. Telephone number of your Financial Institution (including area code)

3c. Name and address of financial institution 3d. Special Note: If you prefer, you may attach a cancelled personal check that 

shows the information requested above, instead of filling in the requested 

financial institution information. If you attach your personal check, it is 

especially important that you contact your bank, credit union, or savings 

institution to confirm that the information on the check is the correct 

information for direct deposit. (Some institutions, especially credit unions, 

use different routing numbers on checks.) We can then use this information

to start paying you by direct deposit. 

4. Do you want Federal income tax withheld from your annuity payments?

Yes (Go to item 4a) No (Go to Section I)

4a. Do you want to have Federal income tax withheld at the rate currently being 

withheld from your salary?

Yes (Attach copy of W-4 form on file with your employing agency.)

No (Attach new W-4 form, otherwise withholding will be at rate for

married with 3 exemptions.)

Section I Applicant's Certification

Warning

Any intentionally false statement in this

application or willful misrepresentation relative 

thereto 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) 

I hereby certify that all statements made in this application are true to the best of my knowledge and belief. 

Signature (Do not print) Date (mm/dd/yyyy)

Applicant's Checklist

This checklist is provided to help you be certain you have attached all necessary documentation and to help your employing office be 

certain it forwards all of your retirement documentation to the Office of Personnel Management. 

Yes No Not 

Applicable 

1. Military Service If you answered "yes" to Section B, Item 4, did you attach Schedule A? 

2. Military Service If you completed Schedule A, did you attach a copy of your discharge certificate or other certificate of 

active military service? 

3. Military Retired Pay If you answered "yes" to Section B, Item 5, did you attach Schedule B? 

4. Military Retired Pay If you completed Schedule B and answered "yes" to Item b or c, did you attach a copy of the notice

of award or other documentation of the type of military retired pay you are receiving? 

5. Military Retired Pay - If you completed Schedule B and answered "yes" to Item d, did you attach a copy of your request 

for waiver and a copy of the military finance office's acknowledgement or approval of your request for waiver (if applicable)? 

6. Survivor Election - If you are married and did not initial box 1 of Section D, did you attach SF 3107-2, Spouse's Consent

to Survivor Election?

7. Life Insurance - If you answered "yes" to Section E, Item 2, did you attach SF 2818, Continuation of Life Insurance Coverage

As an Annuitant or Compensationer? 

8. OWCP - If you answered "yes" to Section F, Item 1, did you attach Schedule C? 

9. Tax - If you want to elect a Federal Income Tax withholding rate, did you attach a W-4 form?
	 	 	 

	 

	 


 


 

	 

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 Standard Form 3107 

NSN 7540-01-255-3670 Previous editions are not usable. Revised June 2006 

Schedules A, B and C

1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number

Schedule A - Military Service Information

1. If you have performed active honorable service in the United States Armed Services or other uniformed services, complete 1a - d below and attach a copy of your discharge 

certificate or other certificate of active military service (if available). 

See instructions for definitions of Armed Services and Uniformed Services.

a.

Branch of service

b.

Serial number

c. Dates of active duty

From (mm/dd/yyyy) To (mm/dd/yyyy)

d. Last grade or 

rank

2. If any of your military service occured on or after January 1, 1957, have you paid a deposit to your agency for this service? (You must pay this deposit to your agency. 

You cannot pay OPM after you retire.)

Yes No Not applicable 

Schedule B - Military Retired Pay

1.

If you are receiving or have applied for military retired or retainer pay (including disability or retired pay), complete Parts 1a - 1d below.

a. Are you receiving or have you ever applied for military retired or retainer pay? 

(Answer "yes" if you are receiving payments from the Department of Veterans 

Affairs instead of military retired pay.) 

Yes No

b. Was your military retired or retainer pay awarded for reserve service under 

Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10)?

Yes (Attach a copy of notice of award) No 

c. Was your military retired pay or retainer pay awarded for a disability incurred 

in combat or caused by an instrumentality of war and incurred in the line of 

duty during a period of war?

Yes (Attach a copy of notice of 

award) 

No

d. Are you waiving your military retired or retainer pay in order to receive credit 

for military service for FERS retirement benefits?

Yes (Attach a copy of your request for

waiver and a copy of military finance 

officer's acknowledgement or approval of 

your request for waiver) 

No

Schedule C - Federal Employees Compensation Information

1. Are you receiving or have you received workers' compensation from the Office of Workers' Compensation Programs (OWCP), Department of Labor, because of a job-related 

illness or injury within the last 2 years?

Yes (complete parts 1a - c below) No (go to question 2)

a.

Compensation claim number

b. Benefit received

From (mm/dd/yyyy) To (mm/dd/yyyy) 

c.

Type of benefit

Scheduled award

Total or partial disability compensation

Scheduled award

Total or partial disability compensation 

2. If you have applied for workers' compensation (other than as listed in item 1a above) but are not receiving benefits, check reason below and give the information requested.

a. Awaiting OWCP decision

Compensation claim number 

b. Claim denied

Compensation claim number Date claim denied (mm/dd/yyyy) 

3. Except for scheduled compensation awards, workers' compensation and FERS retirement benefits be paid for the same period of time. Please complete the 

information below regarding your claim. You must complete this section.

cannot

a. Do you agree to notify us promptly if the status of your workers' compensation claim changes?

Yes No

b. Do you authorize the Office of Personnel Management and/or the Office of Workers' Compensation Programs (OWCP) to collect any overpayment if we later find you 

are not eligible for both compensation and annuity payments covering the same period of time? 

Yes No

Applicant's Certification

I certify that all statements made on

these schedules are true to the best 

of my knowledge and belief.

Signature (do not print) Date (mm/dd/yyyy) 
Federal Employees 	 Retirement System 

	 

	 

	 

	 

	 

	 	 	 

	 	 

	 

	 	 

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 

NSN 7540-01-255-3670 

Certified Summary of Federal Service

Federal Employees Retirement System

Standard Form 3107-1

Previous editions are not usable. Revised June 2006

Office of Personnel 

Management

5 CFR Part 841

Information for the Agency

1. A certified copy of this form must accompany the employee's 

Application for Immediate Retirement (SF 3107) .

2. This form may also be used:

• for retirement counseling purposes 

• to respond to an employee's request for a record of creditable
 service
 

3. See the CSRS and FERS Handbook for Personnel and 

Payroll Offices (formerly FPM Supplement 830-1) for 

detailed instructions for completion and disposition of this 

form. 

Instructions for the Employee

1. Your employing office will complete and certify this form for you.

2. Review this form carefully. Be sure it contains all of your service.

3. Complete Section E, Employee's Certification, and return the form 

to your employing office. 

Section A - Identification

1. Name of employee (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number

4. List all other names used (maiden name, AKA, spelling variants) 5. Other birth dates used 6. Military serial number

7. Service computation date for retirement purposes

8. Did this employee elect to transfer to FERS?

No Yes, give effective date of election:

9. If yes, is this employee entitled, according to your records, to have part of his/her 

annuity computed under CSRS rules?

Yes No

10a. Does the applicant receive military retired pay?

Yes (Attach a copy of the applicant's military retired pay order,

if available, and complete 10b.)

No 

10b. If yes, has the applicant waived military retired pay to credit military service for 

FERS retirement? 

Yes (Attach a copy of the military finance center's letter to the

employee accepting waiver, if available.)

No (Includes cases where a waiver is not necessary.) 

Section B - Verified Service History Documented in Official Personnel Records 

Federal agency or

military service branch

Appointment, separation, or conversion

dates for civilian and active honorable

military service 

From

(mm/dd/yyyy)

To

(mm/dd/yyyy)

Name of retirement 

system*

* Give details of creditable civilian service not subject to retirement deductions in Section C. 

Remarks and non-creditable time** 

**In Remarks, show if CSRS service on or after January 1, 1984, is "regular" CSRS or CSRS Offset.

 Indicate if service is part-time. If service was performed on a WAE or intermittent basis, show the number of hours worked in "Remarks." 
CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 Reverse of Standard Form 3107-1 

NSN 7540-01-255-3670 Previous editions are not usable. Revised June 2006 

Section C - Detail of Civilian Service Not Subject to Contributory Retirement System for Civilian 

 Federal Employees

Detail below (1) any period of Federal civilian service subject only to "FICA" deductions, and (2) any other Federal civilian service not subject to a Federal 

employee (or D.C. Government) retirement system. If total basic salary earned for any such period of service is known, you may make a summary entry on the 

right hand side below. Otherwise, show each change affecting basic salary during the period of service. Show part-time tour of duty, if applicable. If part-time 

service is after April 6, 1986, also provide total number of hours employee worked during the period and show what a full-time tour of duty would be. Service 

which is not subject to FERS or CSRS deductions is creditable only as specifically allowed by law. 

Nature of action

(Appt., pro.,

res., etc.) 

Effective date

(mm/dd/yyyy)

Basic 

salary rate

Salary basis

(per annum,

per hour,

WAE, etc.) 

Leave 

without pay If basic salary actually earned is available

make summary entry below

From

(mm/dd/yyyy)

To

(mm/dd/yyyy)

Total earned

Section D - Agency Certification 

I certify that the information on this form accurately reflects verified information contained in official personnel and/or payroll records in the custody of 

this agency and that the retiring employee has sufficient service for an immediate annuity. 

Signature of authorized agency personnel official

Official Title Date (mm/dd/yyyy) 

Agency name and address, including ZIP Code, telephone number (including

area code), FAX number, and email address

Section E - Employee's Certification

The service listed is complete.

I have additional service. (If you claim additional service, attach signed statement(s) giving dates, positions, titles and locations of employment, 

including agency, bureau, and division. Claimed service cannot be credited for retirement until it has been verified. This includes unverified service 

listed on an SF 144, Statement of Prior Federal Civilian and Military Service, or similar affidavit.) 

Note:	 If you have performed Federal civilian service subject to social security deductions (FICA) or not subject to retirement deductions, be sure that 

your agency has correctly completed Section C above. 

Signature (do not print) Date (mm/dd/yyyy)
	 

	 

	 

	 

	 

(Month) (Year)	 (City and State) 

(Seal) 

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 

NSN 7540-01-255-3670 Previous editions are not usable.

Spouse's Consent to Survivor Election

Standard Form 3107-2

Revised June 2006

Instructions: If you are married and you do not elect a reduced annuity to provide a maximum survivor annuity for your current spouse, 

complete Part 1. Have your spouse complete Part 2. Part 2 must be completed in the presence of a Notary Public or other person authorized to 

administer oaths. The person administering oaths must complete Part 3.

Part 1 - To Be Completed by the Retiring Employee

Name (last, first, middle) Date of birth (mm/dd/yyyy) Social Security Number 

I have elected: (Mark the box which describes the election you have made with regard to your current spouse.)

a. No regular or insurable interest survivor annuity for my current spouse. I understand that: 

 No survivor annuity will be paid to my spouse after my death,

 His/her health benefits coverage will terminate upon my death, and

 He/she will not be eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) after my death. 

b. I am electing an insurable interest annuity for my current spouse, but no regular survivor annuity for my current spouse. (I have completed Section 

D, Item 4 on my Standard Form 3107 naming my current spouse.)

c. A partial survivor annuity (25%) for my current spouse. 

Part 2 - To Be Completed by the Current Spouse of the Retiring Employee 

I freely consent to the survivor annuity election described in Part 1. I understand that if my spouse elected no regular or insurable interest 

survivor annuity in Part 1.a. above, I will not receive a survivor annuity, my health benefits coverage will terminate and I will not be 

eligible to enroll in the Federal Long Term Care Insurance Program (FLTCIP) if I am not already enrolled before my spouse's death. I 

also understand that my consent is final (not revocable). 

Name (type or print) Signature (do not print) Date (mm/dd/yyyy)

Part 3 - To Be Completed by a Notary Public or Other Person Authorized to Administer Oaths 

I certify that the person named in Part 2 presented identification (or was known) to me, gave consent, signed or marked this form and 

acknowledged that the consent was freely given in my presence on this 

the __________ day of _________________________, __________, at _______________________________________________________. 

(Seal of Notary Public or witnessing authority of person authorized to administer oaths) Signature (do not print) 

Expiration date (mm/dd/yyyy) of commission, if Notary Public

General Information: The law requires that a retiring, married 

employee must elect to provide a survivor annuity for a current spouse, 

unless the current spouse consents to an election not to provide the 

maximum survivor benefit. 

A court order which requires a retiring employee to provide a survivor 

annuity for a former spouse is not an election and spousal consent is not 

required. In other words, such a court order does not require a current 

spouse to waive the right to a survivor annuity for the current spouse even 

though the Office of Personnel Management (OPM) must honor the terms 

of the court order before it can honor the election for the current spouse. 

The current spouse may, therefore, receive a smaller annuity than elected, 

or none at all, unless the former spouse loses eligibility for the 

court-ordered survivor annuity (through remarriage before age 55 or 

death). 

Important: If the current spouse consents to an election to provide no 

survivor annuity or a partial survivor annuity and is later divorced from the 

retired employee, the retired employee may not then elect (nor can OPM 

honor a court order) to provide a former spouse annuity which exceeds the 

amount elected at retirement for that spouse. This also applies if the parties 

remarry. 

Privacy Act Statement 

Solicitation of this information is authorized by the Federal Employees Retirement law, (Chapter 84, title 5, U.S. Code), the Federal Employees' Group Life Insurance law 

(Chapter 87, title 5, U.S. Code) and the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code). The information you furnish will be used to identify records 

properly associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a 

unique identifiable claim file. 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 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. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security 

Number. The Government may use your number in collecting and reporting amounts that you owe the Government. Furnishing the Social Security Number, as well as other data, 

is voluntary, but failure to do so may delay or prevent action on the retirement application. 
________________ 

______________________________________________________________________________________________________ 

Federal Employees
 

Retirement System
 

 ____________________________ 



Attached Not 

Applicable 

 _______________________________________________ 

 _______________________________________________ 

3107-106 

CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-255-3670 Previous editions are not usable. Revised June 2006

Agency Checklist of Immediate Retirement Procedures

Federal Employees Retirement System

Standard Form 3107 - Schedule D

Section A - Employing Office Checklist: To be completed by office maintaining Official Personnel Folder (OPF).

1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number 

4. Type of retirement

Immediate Voluntary (MRA+30, 60+20, 62+5)

Immediate Voluntary (MRA+10 with age reduction)

Early Retirement (Major RIF, reorganization, or transfer of function) 

Involuntary Retirement

Disability

5. Special provisions (Check any applicable)

25 Years Law Enforcement/Firefighter

20 Years Law Enforcement/Firefighter and age 50

25 Years Air Traffic Controller

20 Years Air Traffic Controller and age 50

Other:

6. Pay Plan and

Occupational 

Series Code at 

Retirement 

7. Is the applicant eligible to continue health benefits coverage into retirement?

Yes, enrollment code: No, give reason:

8. Does the applicant meet the requirements for the continuation of life insurance into retirement?

Yes, complete 8a. No, give reason:

8a. The applicant can continue Basic Life insurance and the following options: 

No optional insurance Option A - Standard 

Option B - Additional with the following multiples of pay: 

1 2 3 4 5

Option C - Family with the following multiples of pay: 

1 2 3 4 5

9. Are the following documents attached or actions taken? Indicate by an "X" for each item. Attached Not 

Applicable

*See back for titles of forms referred to above.

a. SF 3107*

b. All documents applicant shows as attached to SF 3107

c. If applicant is married and elects less than the maximum survivor benefit, SF 3107-2* 

d. SF 3107-1*

e. If discontinued service retirement, documentation specified in Chapter 44, CSRS/FERS Handbook for Personnel and Payroll Offices 

(formerly FPM Supplement 830-1), including OPM Form 1510* and attachments, if available.

f. If early optional retirement, enter OPM Authority Number here

g. Agency estimate of benefits, if prepared.

h. If applicant wants a refund of military service deposit because he/she does not want to waive military retired pay, SF 3106* 

i. If post-1956 military service deposit is not made, was applicant counseled about the effects of not paying the deposit? Yes No

j. If applicant wants Federal Income tax withheld at the same rate as while an employee, copy of W-4 form on file with your agency.

k. If the annuitant meets the 5-year requirement to continue health benefits into retirement based on previous coverage as a family member 

under someone else's FEHB plan or prior coverage under TRICARE or TRICARE for Life, attach documentation.

l. If a court order requires the annuitant to provide mandatory self and family FEHB coverage for his/her children under P.L. 106-394, a copy 

of the court order.

10. If the type of annuity is not disability, 

are the following documents attached?

(Mark "X" in appropriate column.) 

Attached Not 

Applicable 

Sent to 

OWCP

a. All SF 2809's* in the applicant's OPF

b. All SF 2810's* in applicant's OPF

c. SF 2821*

d. SF 2818*

e. All SF 54's* & SF 2823's* in the applicant's OPF

f. All SF 2817's*, SF 176's*, SF 176T's*

g. All SF 3102's* 

11. If the type of retirement is disability, is the employee's disability documentation specified in SF 3112* attached?

Yes No, explain:

12. List any documents which are attached, but not listed above:

13. Certification by Chief Personnel Officer or Designee

I certify that the above accurately reflects verified information in official records and that the applicant has sufficient service to support title to an annuity. 

Signature (do not print) Address

Official Title Submitting Office Number

(SON)

Person to contact for further information Telephone number FAX number Email address 

Offenses Barring Annuity Payments: Public Law 87-299 prohibits payment of annuity to persons who have committed specified offenses involving the national security of the 

United States. Employing agencies are responsible for submitting all pertinent information to the Office of Personnel Management, Center for Retirement and Insurance Services, 

in any case when this law possibly applies.
	 

	 

	 

	 

	 

	 

	 	 

	 	 

	 

	 

CSRS/FERS Handbook for Personnel and Payroll Offices 3107-106 Reverse of Standard Form 3107 - Schedule D NSN 7540-01-255-3670 Previous editions are not usable. Revised June 2006 

Section B - Payroll Office Checklist: To be completed by the office maintaining the Individual Retirement Record 

 (SF 3100* and SF 3100A*) 

Important: The SF 3100 or SF 3100A for applicant must be closed out and sent to OPM no later than 5 days after the pay date of the final paycheck. 

1. Does the SF 3100 or SF 3100A for the applicant named in Section A contain all 

information necessary to comply with OPM instructions for maintaining the 

Individual Retirement Record? 

Yes No (explain in item 12) 

2. Is the applicant someone who elected to transfer to FERS and who is entitled to 

have a portion of his or her benefits computed under CSRS rules?

Yes (go to item 3) No (go to item 4) 

3. If yes, are his or her sick leave balances at the time of transfer and as of retirement 

shown on SF 3100 or SF 3100A?

Yes No (explain in item 12)

4. Is applicant's last day in pay status shown on SF 3100 or SF 3100A?

Yes No (explain in item 12)

5. Is applicant's health benefits status posted on SF 3100 or SF 3100A?

Yes No (explain in item 12)

6. If this is a preliminary SF 3100 or SF 3100A for disability retirement, is applicant's

life insurance status posted?

Yes No (explain in item 12)

7. If applicant is continuing life insurance into retirement, is the SF 2821 with Payroll Office certifying signature attached?

Yes No (explain in item 12)

8a. Has applicant made a military service deposit with your agency?

Yes (go to item 8b) No (go to item 9a)

8b. If yes, is an SF 3100 or SF 2806* for the deposit attached?

* Employees who elected to transfer to FERS may have a redesignated SF 2806 instead of, or in addition to SF 3100 or SF 3100A.

Yes No Record will follow

9a. Does the applicant have any part-time service (for an employee who elected to

transfer to FERS and is eligible to have a portion of his/her annuity computed

under CSRS rules, any part-time service on or after April 7, 1986)? 

Yes (go to item 9b) No (go to item 10)

9b. If yes, is the number of hours in each scheduled tour of duty and the date of each

change in tour of duty posted on the SF 3100 or SF 3100A (including changes to

full-time and intermittent status)? If the employee worked in excess of his/her 

scheduled tour of duty, post the actual earnings or hours actually worked at each 

rate of pay. 

Yes No (explain in item 12)

10. If the applicant is a postal employee, are postal earnings for

non-deduction service shown on SF 3100?

Yes No (explain in item 12) 

11. Disposition of SF 3100 or SF 3100A: 

SF 3100 or SF 3100A and SF 3103, Register of Separations and Transfers, 

are attached.

SF 3100 or SF 3100A was forwarded as follows: 

Forwarded to: 

SF 3103 number Date (mm/dd/yyyy) of SF 3103

12. Remarks

13. Certification by the Chief Payroll Officer or Designee

I certify that the above reflects official records maintained by this office.

Signature (do not print) Telephone number FAX number Email address 

Payroll Office Number Date (mm/dd/yyyy)

Titles of Forms Referred to in Sections A & B: 

SF 2806 Individual Retirement Record (CSRS)

SF 2809 Employee Health Benefits Election Form

SF 2810 Notice of Change in Health Benefits Enrollment

SF 176, SF 176T, &

SF 2817 Life Insurance Election

SF 2818 Continuation of Life Insurance Coverage As an Annuitant or 

Compensationer

SF 2821 Agency Certification of Insurance Status

SF 54 & SF 2823 Life Insurance Designation of Beneficiary

SF 3100 Individual Retirement Record (FERS)

SF 3100A Individual Retirement Record (FERS) 

SF 3102 FERS Designation of Beneficiary

SF 3103 Register of Separations and Transfers

SF 3106 Application for Refund of Retirement Deductions

SF 3107 Application for Immediate Retirement (FERS)

SF 3107-1 Certified Summary of Federal Service 

SF 3107-2 Spouse's Consent to Survivor Election

SF 3112 Documentation in Support of Disability Retirement

OPM Form 1510 Certification of Agency Offer of Position and Required

Documentation