Authorization For Direct Payments {RI 16-28}

United States Office of Personnel Management Direct Payment Program P.O. Box 979062 St. Louis, MO 63197-9000 Authorization for Direct Payments Using Pre-Authorized Direct Payments you can pay for life insurance and service credit and make Voluntary Contributions by automatic deductions from your checking or savings account--without writing a check and mailing your payments. We deduct for life insurance at the beginning of each month. We deduct service credit and voluntary contributions payments as you specify and mail you a receipt after each deduction. Please check one: New Enrollment Change Enrollment Discontinue Pre-Authorized Direct Payment Service Staple voided check from checking account or deposit ticket or withdrawal ticket from savings account here. I authorize the U.S. Office of Personnel Management (OPM), to initiate debit entries to my Checking or Savings account (select one) indicated below at the depository financial institution named below, hereinafter called depository, and to debit the same to such account. Name Telephone number (including area code) Address (including city, state, & ZIP code) Social Security Number Name of your financial institution Branch City, state, & ZIP code Account number (check only one) Bank routing number Account number Checking Savings Account number Please indicate the payment you are authorizing and give the requested information. Service Payment Amount Date of Birth (mm/dd/yyyy) Account Number Credit (minimum of $50.00) D Life Insurance Premium Voluntary Contributions Account Number CSA L SSN Date of Birth (mm/dd/yyyy) Account Number $ Payment Amount Frequency of Payment: Every Friday Monthly - specify the day: Monthly payment is due the first day of the month. $ Payment Amount (must Frequency of Payment: be in multiples of $25.00) Every Friday Monthly - specify the day: VC $ This authorization is to remain in full force and effect until OPM has received written notification from me of its termination in such time and in such manner as to afford OPM and the Depository a reasonable opportunity to act on it. I may revoke my authorization at any time by providing written notification via a letter or by completing an Authorization for Direct Payments Form provided by OPM and selecting "Discontinue Pre-Authorized Direct Payment Service" enrollment. The letter or Authorization Form must be mailed to the address at the top of this form. Signature Date (mm/dd/yyyy) For OPM Depository Use Only If you have questions ­ call (202) 606-5240 regarding service credit, Date processed call (202) 606-0706 regarding life insurance, call 1-888-828-9451 regarding Voluntary Contributions. Processed by If you need to change the bank account, the payment amount, or the date we deduct monies from your account, send us another Authorization Form in time for us to receive it at least 14 days First scheduled payment date before the regularly scheduled payment date. Mail the form to the address shown above. This form is available on the OPM website at http://www.opm.gov/Forms. PLEASE KEEP THE BOTTOM COPY OF THIS FORM FOR YOUR RECORDS. RETURN TOP TWO COPIES. RI 16-28 Previous editions are not usable. American LegalNet, Inc. www.FormsWorkFlow.com Revised January 2006 Privacy Act Statement Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and the Federal Employees Retirement law (Chapter 84, 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 uniquely 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 the use of the Social Security Number. Furnishing the data requested is voluntary, but failure to do so may delay or make it impossible for us to process this authorization. American LegalNet, Inc. www.FormsWorkFlow.com Reverse of RI 16-28 Revised January 2006