Form Approved 

OMB No. 3206-0140 

United States 

Office of Personnel Management 

Retirement Operations

Boyers, PA 16017

Information Necessary for a Competency Determination 

An original or a certified copy of a court order appointing a guardian or fiduciary to handle the affairs of the individual 

should be submitted so that the Office of Personnel Management can determine whether the applicant is or was 

mentally incompetent or otherwise unable to handle his or her financial or other affairs. Uncertified photocopies are not 

acceptable. The court order should cover the entire period of time which is in question for this determination and 

should address whether the alleged incompetency occurred in the past or is currently present. 

If no guardian or fiduciary is appointed by a court, please provide the information described in both A and B below. 

A. A statement from the physician who has been treating the individual. (The individual or his representative is 

responsible for any cost incurred in obtaining this documentation.) The physician's statement should cover, but 

not be limited to, the time period in question for this competency determination and should address whether the 

alleged incompetency occurred in the past or is currently present. The physician should provide, on his or her 

letterhead stationery, the information listed below. Please provide a copy of this form to the physician.

• History of the specific medical condition(s) which caused the individual to be incompetent, including 

symptoms, physical findings, results of laboratory studies, and therapy (together with the response to 

therapy). Please provide copies of all reports of laboratory studies, in the case of psychiatric disorders, the 

findings of mental status examinations and copies of all psychological test reports, and copies of all 

discharge summaries of hospitalizations and operative reports. 

• The diagnosis should be in accordance with ICD terminology or, in the case of psychiatric disorders, with 

DSM IV criteria. 

• The duration of the medical condition(s), including the date the condition caused incompetency and the date 

or expected date of full or partial recovery. 

B. Affidavits from at least two persons who know the facts concerning the individual's competency, preferably one 

from a member of the individual's immediate family and one from a non-family member. The persons making the 

affidavits should state:

• The relationship to, and amount of contact with, the individual during the relevant time period. 

• What actions or incidents were personally observed which would show whether the individual's condition 

interfered with the ability to handle personal affairs, and how often these were observed. 

• The reason why a guardian or fiduciary was not appointed by the court to handle the affairs of the individual. 

• Who has been handling the individual's affairs. 

(Affidavits must be sworn to or affirmed before a notary public or other officer who is authorized by law to 

administer oaths.) 

Send the documents to the above address. Be sure to include the claim number shown at the top of form RI 20-7, 

Representative Payee Application, with this correspondence. 

Warning 

Affidavits and other evidence are subject to verification by personal investigation. Any intentionally false statement, willful concealment of a 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) 

Public Burden Statement 

We estimate providing this information takes an average 60 minutes per response, including the time for reviewing instructions, getting the needed 

data, and reviewing the requested information. Send comments regarding our estimate or any other aspect of this form, including suggestions for 

reducing time needed, to the Office of Personnel Management (OPM) Retirement Services Publications Team (3206-0140), Washington, D.C.

20415-3430. The OMB Number 3206-0140 is currently valid. OPM may not collect this information, and you are not required to respond, unless this 

number is displayed. 

RI 30-3 

Previous edition is usable Revised June 2013