See Privacy Act

Information on
Federal Employees
Application for Immediate Retirement Instruction Sheet
Retirement System
Federal Employees Retirement System
Section A - Identifying Information
1. Name (last, first, middle) 2. List all other names you have used
KIM KATE
3. Address (number, street, city, state, ZIP code) 4a. Daytime telephone # after retirement (including area 4b. Best time to reach you
code)
KYIV UKRAINE (095) 248-3978 11AM
4c. Home email address 4d. FAX Number
kimkate81991@gmail.com
5. Date of birth (mm/dd/yyyy) 6. Social Security Number
08/27/1991 666-41-0958
7. Are you a citizen of the United States of America? 8. Is this an application for disability retirement?

Yes No 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)
UNITED STATES ARMY 06/21/2022
3. Title of position from which you are
retiring
AIR FIELD MARSHAL COLONEL
3a. Your pay plan and occupational series
LIFE PAYMENT
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 and attach a copy of your marriage certificate) 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 or a portion of your retirement benefits based on your Federal employment?

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 survivor annuity for a former spouse or within
2 years of a post-retirement marriage to elect a survivor annuity for a spouse acquired after retirement. 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.
If you want to elect a partial survivor annuity for your current spouse and a survivor benefit for a former spouse, you should complete options 2 and 5 below.
The total of the survivor annuities elected cannot exceed 50 percent. An election of an insurable interest survivor in option 4 is not included when determining
the 50 percent maximum.
1. Initials 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
earned annuity.
2. Initials 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 earned 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.
3. Initials 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.
3107-108 Standard Form 3107
CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
4. Initials 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.) If you are married and elect this option for your spouse, complete SF 3107-2, Spouse's Consent to Survivor
Election and attach it to your application.
Name of person with insurable interest Relationship to you Date of birth (mm/dd/yyyy) Social Security Number

KIM BOK-GI HUSBAND TO BE (spouse) 10/07/1969

5. Initials 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.
Name and address of former spouse Date of marriage Date of divorce
(mm/dd/yyyy) (mm/dd/yyyy) Survivor annuity equal

Date of birth Social Security Number to _______________%

(mm/dd/yyyy)
of my annuity
Name and address of former spouse Date of marriage Date of divorce
(mm/dd/yyyy) (mm/dd/yyyy) Survivor annuity equal

Date of birth Social Security Number to _______________%

(mm/dd/yyyy)
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 1b. Is there a court order or administrative order currently in effect that requires
retiree? you to provide health benefits coverage for your child(ren)?

Yes No 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 enrolled in the Federal Dental and Vision Insurance Program (FEDVIP)?

Yes  Your coverage will automatically continue into retirement as long as you continue to pay applicable premiums. Until work on your
annuity is completed, you may receive bills from BENEFEDS. You must pay these bills in order to keep your FEDVIP coverage.
After work on your annuity is completed, BENEFEDS will automatically begin deducting from your annuity to pay future premiums.
If you have questions, please contact BENEFEDS at 1-877-888-3337.

No  If you retire on an immediate annuity, you can enroll in FEDVIP during any Federal Benefits Open Season.
4. 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. Have you applied for, are you receiving, or have you ever received 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 2b. Claim number(s)

Retirement Return of excess deductions Voluntary contributions

Section G (Optional) - Information About Your Unmarried Dependent Children
1. Dependent child's name 2. Date of birth 3. Disabled 1. Dependent child's name 2. Date of birth 3. Disabled
(first, middle, last) (mm/dd/yyyy) () (first, middle, last) (mm/dd/yyyy) ()

3107-107 Standard Form 3107

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
 Section H - Payment Instructions
1. Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by
the Department of the Treasury. See the instructions for Section H of this application and SF 3113 (Applying for Immediate Retirement Under the Federal
Employees Retirement System) for additional information. This does not apply to you if your permanent payment address is outside the United States in a
country not accessible via direct deposit.

Please select one of the following:

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

Please send my annuity payments to my Direct Express debit card. (Go to item 3a)

My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to item 3a)

2a. Financial Institution Routing Number You may obtain this number by calling your bank, credit union, or savings institution.
111000025 This number is very important. We cannot pay by direct deposit without it.
2b. Checking or Savings Account Number 2c. What kind of account is this? 2d. Telephone number of your Financial Institution (including area code)
488076405170 Checking Savings
2e. Name and address of Financial Institution Special Note: If you prefer, you may attach a cancelled personal check that
BANK OF AMERICA 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
4950 Keller Springs Rd 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
Ste 400 Addison TX 75001
to start paying you by direct deposit.
3a. Do you want Federal income tax withheld from your annuity payments? 3b. 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.)
Yes (Go to item 3b) No (Go to Section I) No (Attach new W-4 form, otherwise withholding will be at rate for
married with 3 exemptions.)
Section I - Applicant's Certification
Warning I hereby certify that all statements made in this application are true to the best of my knowledge and belief.
Any intentionally false statement in this
application or willful misrepresentation relative
thereto is a violation of the law punishable by a Signature (Do not print) Date (mm/dd/yyyy)
fine of not more than $10,000 or imprisonment of 05/21/2022
not more than 5 years, or both. (18 U.S.C. 1001)
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 Yes No Not
certain it forwards all of your retirement documentation to the Office of Personnel Management. 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 acknowledgment 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?
10. Court or Administrative Order(s) - If you answered "yes" to Section C, item 2 and/or "yes" to Section E, Item 1b, did you attach
a copy of the order(s)?

3107-108 Standard Form 3107

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
 Schedules A, B and C
1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number
KIM KATE 08/27/1991 666-41-0958

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. b. c. Dates of active duty d. Last grade or
Branch of service Serial number
From (mm/dd/yyyy) To (mm/dd/yyyy) rank

KYIV, UKRAINE 38060 12/06/2012 05/23/2022 COLONEL

2. If any of your military service occurred 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
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? b. Was your military retired or retainer pay awarded for reserve service under
(Answer "yes" if you are receiving payments from the Department of Veterans Chapter 1223, title 10, U.S. Code (formerly Chapter 67, title 10)?
Affairs instead of military retired pay.)

Yes No Yes (Attach a copy of notice of award) No

c. Was your military retired pay or retainer pay awarded for a disability incurred d. Are you waiving your military retired or retainer pay in order to receive credit
in combat or caused by an instrumentality of war and incurred in the line of for military service for FERS retirement benefits?
duty during a period of war?
Yes (Attach a copy of your request for No
Yes (Attach a copy of notice of No waiver and a copy of military finance
award) officer's acknowledgment or approval of
your request for waiver)
Schedule C - Federal Employees Compensation Information
1. Are you receiving or have you ever received workers' compensation from the Office of Workers' Compensation Programs (OWCP), Department of Labor, because of a
job-related illness or injury?

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

a. b. Benefit received c.
Compensation claim number Type of benefit
From (mm/dd/yyyy) To (mm/dd/yyyy)
Scheduled award Other
Total or partial disability compensation
Scheduled award Other
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 b. Claim denied

Compensation claim number Compensation claim number Date claim denied (mm/dd/yyyy)
4890-0065
3. Except for scheduled compensation awards, workers' compensation and FERS retirement benefits cannot be paid for the same period of time. Please complete the
information below regarding your claim. You must complete this section.
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 Signature (do not print) Date (mm/dd/yyyy)
these schedules are true to the best
of my knowledge and belief. 05/21/2022

3107-108 Standard Form 3107

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
 Office of Personnel
Management
Federal Employees Certified Summary of Federal Service 5 CFR Part 841
Federal Employees Retirement System
Retirement System

Information for the Agency Instructions for the Employee

1. A certified copy of this form must accompany the employee's 1. Your employing office will complete and certify this form for you.
Application for Immediate Retirement (SF 3107). 2. Review this form carefully. Be sure it contains all of your service.
2. This form may also be used: 3. Complete Section E, Employee's Certification, and return the form
• for retirement counseling purposes to your employing office.
• 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 for detailed instructions for completion and
disposition of this form.

Section A - Identification
1. Name of employee (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number
KIM KATE 08/27/1991 666-41-0958
4. List all other names used (maiden name, AKA, spelling variants) 5. Other birth dates used 6. Military serial number
9163-6798-587
7. Service computation date for retirement purposes
05/29/2022
8a. Did this employee elect to transfer to FERS? 8b. If the employee elected to transfer to FERS, is the employee entitled, according to
your records, to have part of the FERS annuity computed under CSRS rules?

No Yes, give effective date of election: Yes No

9a. Does the applicant receive military retired pay? 9b. If yes, has the applicant waived military retired pay to credit military service for
FERS retirement?

Yes (Attach a copy of the applicant's military retired pay order, Yes (Attach a copy of the military finance center's letter to the
if available, and complete 9b.) employee accepting waiver, if available.)
No No (Include cases where a waiver is not necessary.)
Section B - Verified Service History Documented in Official Personnel Records
Federal agency or Appointment, separation, or conversion Name of retirement Remarks and non-creditable time**
military service branch dates for civilian and active honorable system*
military service
From To
(mm/dd/yyyy) (mm/dd/yyyy)
UNITED STATES ARMY 12/06/2012 HONORARY / DUE FOR RETIREMENT UPON THE AGREED
05/23/2022
KYIV CITY, UKRAINE IMMEDIATE TERM OF SERVICE AND WILLING TO SETTLE
VOLUNTARY DOWN

* Give details of creditable civilian service not subject to retirement deductions in Section C.
**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 days worked in "Remarks." If the number of days worked is not
available, then show the number of hours worked.

3107-108 Standard Form 3107-1

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
 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. Also
provide total number of hours the employee worked during the period of part-time service, if available, 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 Effective date Basic Salary basis Leave If basic salary actually earned is available
(Appt., pro., (mm/dd/yyyy) salary rate (per annum, without pay make summary entry below
res., etc.) per hour,
WAE, etc.)
From To Total earned
(mm/dd/yyyy) (mm/dd/yyyy)

Section D - Agency Certification

I certify that the information on this form accurately reflects verified information contained in official records and that the applicant has sufficient service to be
entitled to an annuity. I further certify that all required documentation in support of this application is attached, accurate and complete.
Signature of authorized agency personnel official Agency name and address, including ZIP Code, telephone number (including
area code), FAX number, and EMAIL address
CHRISTINE WORMUTH
(312) 560-1110

Official Title Date (mm/dd/yyyy)

United States Military Secretary 05/21/2022
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)

05/21/2022

3107-108 Reverse of Standard Form 3107-1

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
 Spouse's Consent to Survivor Election
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
KIM KATE 08/27/1991 666-41-0958

I have elected: (Mark the box(es) which describes the survivor election(s) you have made. More than one box may be marked.)
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. 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.

d. A maximum survivor annuity for my former spouse _________________________________________________________.

(name of former spouse)
e. A partial survivor annuity for my former spouse _______________________________________________________ equal to 25% of my annuity.
(name of former spouse)
f. A partial survivor annuity for my former spouse _______________________________________________________ equal to 25% of my annuity.
(name of former 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)
KIM BOK-GI 05/21/2022
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

21st day of _________________________,

the __________ April 2022 at _______________________________________________________.
__________, Washington DC 20415
(Month) (Year) (City and State)

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

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

02/20/2023
General Information: The law requires that a retiring, married employee The current spouse may, therefore, receive a smaller annuity than elected,
must elect to provide a survivor annuity for a current spouse, unless the or none at all, unless the former spouse loses eligibility for the court-ordered
current spouse consents to an election not to provide the maximum survivor annuity (through remarriage before age 55 or death).
survivor benefit.
Important: If the current spouse consents to an election to provide no
A court order which requires a retiring employee to provide a survivor survivor annuity or a partial survivor annuity and is later divorced from the
annuity for a former spouse is not an election and spousal consent is not retired employee, the retired employee may not then elect (nor can OPM
required. In other words, such a court order does not require a current honor a court order) to provide a former spouse annuity which exceeds the
spouse to waive the right to a survivor annuity for the current spouse even amount elected at retirement for that spouse. This also applies if the parties
though the Office of Personnel Management (OPM) must honor the terms remarry.
of the court order before it can honor the election for the current spouse.
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.

3107-108 Standard Form 3107-2

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
 Federal Employees
Agency Checklist of Immediate Retirement Procedures
Retirement System
Federal Employees Retirement System
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

TATUM KING 04/22/1970 904-82-4082

4. Type of retirement 5. Special provisions (Check any applicable) 6. Pay Plan and
Occupational
Immediate Voluntary (MRA+30, 60+20, 62+5) 25 Years Law Enforcement/Firefighter Series Code at
Retirement
Immediate Voluntary (MRA+10 with age reduction) 20 Years Law Enforcement/Firefighter and age 50
Early Retirement (Major RIF, reorganization, or transfer of function) 25 Years Air Traffic Controller
Involuntary Retirement 20 Years Air Traffic Controller and age 50 LIFE TIME
Disability Other: CONTRACT TERM/ MARRIAGE
____________________________
7. Is the applicant eligible to continue health benefits coverage into retirement?
8254410
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: Option C - Family with the following multiples of pay:
1 2 3 4 5 1 2 3 4 5
9. Are the following documents attached or actions taken? Indicate by an "X" for each item. Attached Not
Applicable
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,
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 has military service, DD 214 or its equivalent, if available
i. If applicant wants to waive military retired pay, copy of waiver request and response from Military Retired Pay Center, if available
j. If applicant served in the military, or applied for military retired pay or DOVA benefits in lieu of military retired pay, or applied for OWCP
benefits, Schedules A, B, C of SF 3107.
k. If applicant wants a refund of military service deposit because he/she does not want to waive military retired pay, SF 3106*
l. If post-1956 military service deposit is not made, was applicant counseled about the effects of not paying the deposit? Yes No
(See OPM Form 1515*)
m. 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.
n. 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 the Uniformed Services Health Benefits Program, attach documentation.
o. 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.
p. If law enforcement officer/firefighter/air traffic controller/Customs and Border Protection Officer/Nuclear Materials Courier, agency
certification of service that makes the applicant eligible for an enhanced annuity benefit.
q. If employee has applied for compensation benefits, OWCP award, if available
10. If the type of annuity is not disability, are the following documents attached? (Mark "X" in appropriate column.)

Attached Not Sent to Attached Not

Applicable OWCP Applicable
a. All SF 2809's* in the applicant's OPF e. All SF 54's* & SF 2823's* in the applicant's OPF
b. All SF 2810's* in applicant's OPF f. All SF 2817's*, SF 176's*, SF 176T's*
c. SF 2821* g. All SF 3102's*
d. SF 2818* h. RI 76-10*, if applicable
11. If the type of retirement is disability, is the employee's disability documentation specified in SF 3112* attached?

Yes No, explain: ______________________________________________________________________________________________________

3107-108 Standard Form 3107 - Schedule D (Page 1 of 3)

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
12. List any documents which are attached, but not listed above:
OFFICIAL RETIREMENT CERTIFICATE - DATED FOR 24TH MAY, 2022
CERTIFICATE OF APPRECIATION FOR SPOUSE - HUSBAND TO BE
DD FORM 108, APPLICATION FOR RETIRES PAY BENEFIT - FEB 2022 DD0108
DD FORM 2789 (WAIVER REMISSION OF INDEBTEDNESS APPLICATION) DD2789

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. I further certify that all required documentation in support of this application is attached, accurate and complete.

Signature (do not print) Address

90 7TH STR., SUITE 18-300
Official Title SAN FRANCISCO, CA 94103
CHAIRPERSON / EXECUTIVE DIRECTOR
Person to contact for further information Submitting Office Number (SON)

TATUM KING 84912-8441

Email address Telephone number FAX number

russell.sara.l@dol.gov 415-625-7723

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, Retirement
Services, in any case when this law possibly applies.
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 30 days after the pay date of the final paycheck.
Yes No**

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?
2. Is his or her sick leave balance as of retirement shown on SF 3100 or SF 3100A?

3a. 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?
3b. 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?

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

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

6. If this is a preliminary SF 3100 or SF 3100A for disability retirement, is applicant's life insurance status posted?

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

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

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

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)?
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.

10. If the applicant is a postal employee, are postal earnings for non-deduction service shown on SF 3100?

11. Disposition of SF 3100 or SF 3100A:

SF 3100 or SF 3100A and Register of Separations and Transfers (SF 3103) are attached***.
If SF 3100 or SF 3100A was already forwarded, provide the following:
Forwarded to: SF 3103 number Date (mm/dd/yyyy) of SF 3103

selection_assessment@opm.gov 05/21/2022
* See page 3 of 3 for titles of forms referred to above.
** Explain any "No" responses in item 12 on the next page.

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

3107-108 Standard Form 3107 - Schedule D (Page 2 of 3)

CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Revised May 2014
*12. Explain any "No" responses here:
APPLICATION FOR IMMEDIATE RETIREMENT AS STATED ON CONTRACT LETTER
DUE FOR MARRIAGE

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

202-606-7228
Payroll Office Number Date (mm/dd/yyyy) Email address

982-114 05/21/2022 NIL

Titles of Forms Referred to in Sections A & B:
SF 2806 Individual Retirement Record (CSRS) SF 3103 Register of Separations and Transfers

SF 2809 Employee Health Benefits Election Form SF 3106 Application for Refund of Retirement Deductions
SF 2810 Notice of Change in Health Benefits Enrollment
SF 3107 Application for Immediate Retirement (FERS)

SF 176, SF 176T, &

SF 2817 Life Insurance Election SF 3107-1 Certified Summary of Federal Service
Continuation of Life Insurance Coverage As an Annuitant or

SF 2818 Compensationer
SF 3107-2 Spouse's Consent to Survivor Election
SF 2821 Agency Certification of Insurance Status SF 3112 Documentation in Support of Disability Retirement
SF 54 & SF 2823 Life Insurance Designation of Beneficiary
OPM Form 1510 Cert. of Agency Offer of Position and Required Doc.
SF 3100 Individual Retirement Record (FERS) OPM Form 1515 Military Service Deposit Election
SF 3100A Individual Retirement Record (FERS) RI 76-10 Assignment FEGLI Program
SF 3102 FERS Designation of Beneficiary DD 214 Certificate of Release or Discharge from Active Duty

Standard Form 3107 - Schedule D (Page 3 of 3)

Revised May 2014