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U.S. Office of Personnel Management - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

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Privacy Act and Public Burden Statements

Privacy Act Title 5, U.S. Code, Chapter 83, Civil Service Retirement and Chapter 84, Federal Employees Retirement System authorize solicitation of this information. The data you furnish will be used to submit a claim for your missing payment. This 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 to determine and issue benefits under their programs 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 the use of the Social Security number as an individual identifier to distinguish between people with the same or similar names. Failure to furnish the requested information may result in OPM being unable to assist you.

Public Burden We think this form usually takes 10 minutes per response to complete; on occasion it may take up to 30 minutes, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management, OPM Forms Officer (3206-0187), Washington, DC 20415-7900. The OMB number, 3206-0187 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

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