5. Pay Period

4. Date payroll paid

2. Payroll office number

From

3. Report number

To

6. To 7. Name of preparer (print) 8. Telephone number

Date

Number Enrolled

Dollar Amount

A. Life Insurance

1. Basic

2. Standard - Option A

Benefit Category Deductions Made No Deductions Made

3. Additional - Option B

a. To age 35

b. 35 - 39

c. 40 - 44

d. 45 - 49

e. 50 - 54

f. 55 - 59

g. 60 & up

4. Family - Option C

5. Post-Retirement - Basic

1. Regular

2. Payers of Full Premiums

3. Total Health Benefits* 

Office of Personnel Management

CSRS/FERS Handbook for Personnel and Payroll Offices

This form may be locally reproduced

Previous editions unusable

OPM Form 1523

Revised September 1996

1. Address of Payroll Office (including department, bureau,

location and zipcode)

Supplemental Semiannual Headcount Report

Office of Personnel Management

ATTN: Funds Control Branch

P.O. Box 582

Washington, D.C. 20044-0582

Signature of authorized official

9. I certify that the items listed herein are correct.

B. Health Benefits

6. Total Life Insurance*
Supplemental Semiannual Headcount Report

Payroll office number Report number Payroll paid date

Benefit Category Dollar Amount Aggregate Base

Salary Number Enrolled

C. Retirement

1. CSRS CPDF

Code Deductions Made No DeductionsMade

a. Regular Withholdings 1,R

Page 2

b. Regular Contributions 1,R

c. Special Withholdings 6,T

d. Special Contributions 6,T

e. Regular Withholdings

for Offset Employees

f. Regular Contributions

for Offset Employees

g. Special Withholdings

for Offset Employees

h. Special Contributions

for Offset Employees

i. Salary Offset

j. Military Deposits

k. Civilian Service Credit

2. FERS

a. Regular Withholdings

b. Regular Contributions

c. Reserve Technicians

Withholdings

d. Reserve Technicians

Contributions

e. A/T Controllers

Withholdings

f. A/T Controllers

Contributions

g. Law Enforcement/Firefighters Withholdings

h. Law Enforcement/Firefighters Contributions

i. Salary Offset

j.

k. Military Deposits

3. Total Retirement*

D. Grand Total (Dollars only)

E. Total Employees (and/or Annuitants) on Payroll

C

C

E

E

K

K

N

N

L

L

M

M

**

**

**

**

**

*Dollar amount must agree with SF 2812 for same reporting period.

**Memo entry only (do not include on line 3, Total Retirement).

Reverse of OPM 1523

Revised September 1996
Report of Withholdings and Contributions for Health Benefits By Enrollment Code

Department or establishment Payroll Office number Report number

Bureau, division or office Pay period from Pay period to

Address (including ZIP Code) Date payroll paid

Agency telephone number

( )

Enrollment

Code No.

Total Withholdings

& Contributions

Number

enrolled*

Enrollment

Code No.

Total Withholdings

& Contributions

Number

enrolled*

Enrollment

Code No.

Total Withholdings

& Contributions

Number

enrolled*

*Number of enrollees is required on report for the last payroll

paid in March and September

This form may be locally reproduced

9/79 edition usable; all other editions obsolete and unusable

Standard Form 2812-A

Revised August 1988

Office of Personnel Management

CSRS/FERS Handbook for Personnel and Payroll Offices