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Application For Refund of Retirement Deductions OMB …

Federal Employees Retirement System Application For Refund of Retirement Deductions Federal Employees Retirement System To avoid delay in payment: (1) Complete both sides of Application in full; (2) Type or print in ink. Form Approved: OMB Number 3206-0170 See the attached sheets for instructions and information concerning your Application for Refund of Retirement Deductions and a Privacy Act Statement. 1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number 4. List all other names you have used (including maiden name, if applicable.)

deductions were withheld from your salary. (Check one) Have you paid deposit or redeposit for any period ... U.S. Office of Personnel Management Revised September 2013 ... you may invoke your legal right to a waiver of the Direct Deposit requirement, and continue to receive your payment by check. Therefore, you must select one of the following ...

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