Complete
and Return for Estimate
Name
|
Address |
Special Retirement?
Law Enforcement Firefighter ATC Postal CBPO Other __________ |
Phone/Email | Retirement
System CSRS/Offset FERS |
Date of Birth | Did you Transfer
to FERS? |
Service Comp Date: | If so,
date & SL Balance |
Date(s) of Retirement: | When
did you start with the govt? |
|
|
Military Time (to/From) | Paid In? Yes/No Pre Interest Amount? |
|
|
Temporary
Time (to/From) | Paid In? Yes/No Pre Interest Amount? |
|
|
Part Time or WAE
Service? Amount of Hours/Week | Dates: (Mo/Day/Yr) |
|
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Withdrawn Time (to/from) | Paid back? Yes/No Amount Withdrawn? |
|
|
Multiple Agency Work? | List Agencies and To/From dates |
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If
Retiring in the next three years,
list last 3 years salary amounts and dates of salary change (include
locality pay):
(Mo/Day/Yr) format | If Retirement is more than 3 years
out, List current salary (including locality) and anticipated pay increase percent for raises:
Current Salary: |
Do not use W-2s or Income Tax records | % Pay Increases: |
| Date of Last Within Grade: |
| Current Grade and Step: |
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Survivor Benefit Desired:
(1) CSRS/Offset: 0% to 100%: ____% or amount per month for survivor.
(2) FERS (mark one): 0%, 25% or 50%
Sick Leave Hours to be Saved Each Pay Period (Hours - biweekly): 0 1 2 3 4
Sick Leave Saved To Date or at time of transfer (Hours) ____________
Former
Spouse Eligible for Survivor Annuity or Divorce in Progress? Yes No -if yes, bring decree.
Amount of Social Security at Age 62 ________ (from SS Statement)
Federal
Employees Health Benefits Program Name of Carrier __________ Biweekly
Cost______ TRICARE Eligible? Y/N
Federal Employees Group Life Insurance Coverage
Basic:
Yes No If Yes, Reduction at age 65 (pick one): None, 50%, 75%
Option A: Yes No
Option B: Yes No If Yes, How Much? 1 2 3 4 5 Times
Reduce After Age 65? Yes No
Option C:
1. Spouse Covered: Yes No
If yes, How Much? 1 2 3 4 5 Times Coverage
Reduce After Age 65? Yes No
2. Dependents Covered:
Current Age: ____ Age: ____ Age: ____ Age: ____
Coverage
Eligible after Age 22: Yes / No Yes / No
Yes / No Yes / No
Thrift Savings Plan
- Savings and Withdrawal
Current Savings in: C Fund: $______,
F Fund: $_______, G Fund: $______, I Fund: $________,
S Fund: $ _______ L Fund $ ______ Which L Fund?
_____
Investing
Percent of Salary _________% or Dollar Amount
per paycheck: ___________
Percent Going to Each Fund: C Fund: _____%, F Fund: _____%, G Fund:
_______% I Fund: % ______
S Fund: % _______ L Fund %_______ Which L Fund? _______
Catch
up Contributions: Year_______ Amount ______ Year _____ Amount ________
Withdrawal
(if known):
Withdrawal (to start): Month _______, Year _______ or approximate age _______
(must start by the year after you turn 70.5)
Withdrawal choice (mark one): Lump Sum: ___, Series of Payments: ___, or Annuity: ___
