Financial Resources Questionnaire {RI 34-1}

Form approved: OMB No. 3206-0167 Financial Resources Questionnaire U.S. Office of Personnel Management Retirement Operations General Information The purpose of this questionnaire is to determine your eligibility for: 1. 2. 3. 4. waiver of the amount due the retirement system on the basis of financial hardship; compromise in the amount to be repaid; lower installments; and/or a voluntary repayment agreement. Item 6 Enter all other current income not listed. This may include unemployment compensation, public assistance benefits, trust income, tax refunds, alimony, child support, royalties, payments of debts owed to you, income provided by dependents listed in Section I (other than spouse), etc. Estimate the average monthly amount. For more information on waiver, compromise, lower installments, or voluntary repayment, please refer to our letter or notice informing you of the overpayment. (Note: If you are only requesting lower installments, you do not need to fill out this questionnaire as long as your payments will be (1) at least $50 a month and (2) sufficient to pay off the entire amount within three years.) Failure to supply all the requested information may result in an unfavorable decision. Please note that you may be asked to provide verification of the information you supply in this questionnaire (e.g., evidence of claimed expenses). To be considered for waiver, compromise, lower installments, or a voluntary repayment agreement, you must complete and return this questionnaire to us within 30 days after the date shown in the notice of overpayments. General Instructions 1. 2. 3. Please read all items carefully. Type or print in ink. Complete all items on the form. If a question does not apply, answer "No" or "None". Do not leave it blank. If answers require additional space, continue them in Section X. Attach additional sheets if necessary. Include your name and retirement claim number in the upper right corner of each additional sheet. Sign and date this questionnaire in Section XI. Send the completed form to: Office of Personnel Management Attn: Funds Management P.O. Box 7125 Washington DC 20044-7125 Section V - Average Monthly Expenses Item 1 Enter the amount you currently spend on average for rent, mortgage, homeowner/condominium fees, etc., each month. If you include property taxes in this item, do not include them in V.9. Item 3 Enter the average monthly amount you spend for electricity, telephone, gas, water, coal, oil, etc. Item 4 Enter the average monthly amount you spend for household maintenance (repairs, cleaning supplies, etc.) and personal necessities. Item 7 Enter the average monthly amount you spend for insurance (life, health, accident, automobile, homeowners, etc.). Do not include homeowner's insurance if it is already included in item V.1. Item 8 Transportation costs include necessary automobile expenses (gas, oil, maintenance), cab fares, and public transportation. Item 9 Enter 1/12 of all taxes you pay in a year, including Federal, state, and local taxes; property taxes not included in item V.1; sales taxes not included in other items, etc. Item 10 Enter the total amount due monthly from existing liabilities as shown in Column E of Section VII. (This amount should not include any expenses - such as mortgage payments - listed under other items in Section V.) Item 11 Other living expenses which you can prove to be ordinary and necessary. Provide a breakdown of these expenses in Section X. Section VIII - Assets Item 4 Enter the cash value of your money market accounts, certificates of deposit, etc. Do not include Individual Retirement Accounts (IRA's) or other interest bearing accounts which belong in item 6. Item 5 The current value on any stocks or bonds you own. The current value is the amount you would receive if you sold these securities. Item 6 The current value of any IRA's, Keoughs or similar retirement savings accounts. Item 8 Identify any automobiles, vans, trucks, motorcycles, motor homes (RV's), trailers, campers, boats, etc., that you own, and their resale value (the amount you would receive if you sold these vehicles). Any remaining liabilities for these vehicles should appear in Section VII. Item 9 The resale value of your home and other real estate. (If you own two or more properties, list separately. Also show the unpaid amount of any real estate mortgages in Section X.) Item 10 The current resale value of any other personal property (art pieces, jewelry, etc.) which can be sold and which are valued in excess of $1,000 per item. (Itemize in Section X.) 4. 5. Detailed Instructions Most of the questionnaire items are self-explanatory. Instructions are provided below for those items identified with an asterisk(*), which require further explanation. Section I - Personal Data Item 1 Give the name of the former Federal employee upon whose service your entitlement to retirement system benefits was based. (If the benefits are based upon your own service, give your name.) Section IV - Average Monthly Income Item 1 Enter your current monthly gross salary - i.e., wages, fees, commissions - for yourself and then your spouse. (Enter the total salary paid before any payroll deductions are made; e.g., Federal, state, and local taxes; social security taxes; insurance, etc.). If your salary fluctuates on a monthly basis, estimate the monthly average. Previous edition is usable RI 34-1 Revised May 2012 American LegalNet, Inc. www.FormsWorkFlow.com Financial Resources Questionnaire For Consideration in Connection With Collection of an Overpayment Please read the attached instructions and Privacy Act Statement before completing this form. Section I - Personal Data *1. Name of former Federal employee (Last, first, middle) 2. Claim number 3. Former Federal employee's date of birth (mm/dd/yyyy) Your social security number 4. Your name 5. Your date of birth (mm/dd/yyyy) 6. 7. Your address 8. 9. Your telephone number (including area code) Your email address 10. Your dependents (list spouse first): Name (Last, first, middle) Relationship Date of Birth Social Security Number Section II -Your Current/Most Recent Employment 1. Current or most recent position (e.g., Salesclerk) 2. Dates of employment From (mm/yyyy) To (mm/yyyy) Section III -Spouse's Current/Most Recent Employment 1. Current or most recent position (e.g., Salesclerk) 2. Dates of employment From (mm/yyyy) To (mm/yyyy) 3. Name and address of employer 3. Name and address of employer Section IV -Average Mon