Supplemental Semiannual Headcount Report {OPM 1523}

Supplemental Semiannual Headcount Report 1. Address of Payroll Office (including department, bureau, location and zip code) 2. Payroll Office Number Form Approved OMB No. 3206-0262 3. Report Number 4. Date Payroll Paid 5. Pay Period From To 6. To Office of Personnel Management ATTN: Funds Management P.O. Box 582 Washington, D.C. 20044-0582 7. Name of Preparer (print) 8. Telephone Number 9. I certify that the items listed herein are correct. Signature of authorized Date official Number Enrolled Benefit Category A. Life Insurance 1. Basic 2. Standard - Option A 3. Additional - Option B a. To age 35 b. 35-39 c. 40-44 d. 45-49 e. 50-54 f. 55-59 g. 60 & up 4. Family - Option C 5. Post-Retirement - Basic 6. Total Life Insurance * B. Health Benefits 1. Regular 2. Payers of Full Premiums 3. Total Health Benefits * * Dollar amounts must agree with SF 2812 for same reporting period. Dollar Amount Deductions Made No Deductions Made Public Burden Statement We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completing time, to the Office of Personnel Management, Funds Management, P.O. Box 582, Washington, DC 20044. The OMB Number 3206-0262 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices This form may be locally reproduced Previous editions unusable OPM Form 1523 Revised November 2013 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Supplemental Semiannual Headcount Report Payroll Office Number Report Number Aggregate Base Salary Payroll Paid Date Benefit Category C. Retirement 1. CSRS a. Regular Withholdings b. Regular Contributions c. Special Withholdings d. Special Contributions e. Regular Withholdings for Offset Employees f. Regular Contributions for Offset Employees g. Special Withholdings for Offset Employees h. Special Contributions for Offset Employees i. Salary Offset j. Military Deposits k. Civilian Service Credit 2. FERS a. Regular Withholdings b. Regular Contributions c. Reserve Technicians Withholdings d. Reserve Technicians Contributions e. A/T Controllers Withholdings f. A/T Controllers Contributions g. Law Enforcement/Firefighters Withholdings h. Law Enforcement/Firefighters Contributions i. Salary Offset j. k. Military Deposits K K N N L L M M CPDF Code Dollar Amount Number Enrolled Deductions Made No Deductions Made 1,R 1,R 6,T 6,T C C E E ** ** ** ** ** * Dollar amounts must agree with SF 2812 for same reporting period. ** Memo entry only (do not include on line 4, Total Retirement). OPM 1523 Revised November 2013 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Supplemental Semiannual Headcount Report Payroll Office Number Report Number Aggregate Base Salary Payroll Paid Date Benefit Category C. Retirement - Continued 3. FERS-RAE a. Regular Withholdings-RAE b. Regular Contributions-RAE c. Reserve Technicians Withholdings-RAE d. Reserve Technicians Contributions-RAE e. A/T Controllers Withholdings-RAE f. A/T Controllers Contributions-RAE g. Law Enforcement/Firefighters Withholdings-RAE h. Law Enforcement/Firefighters Contributions-RAE i. Salary Offset-RAE j. k. Military Deposits-RAE 4. Total Retirement* D. Grand Total (Dollars only) MR CPDF Code Dollar Amount Number Enrolled Deductions Made No Deductions Made KR KR NR NR LR LR MR ** ** E. Total Employees (and/or Annuitants) on Payroll * Dollar amounts must agree with SF 2812 for same reporting period. ** Memo entry only (do not include on line 4, Total Retirement). OPM 1523 Revised November 2013 Page 3 American LegalNet, Inc. www.FormsWorkFlow.com