Urgent Reply Required Within 30 Days To Avoid Interruption Of Your Payments {RI 38-107}

United States Office of Personnel Management 1900 E Street, NW Washington, DC 20415-3564 Form Approved: OMB No. 3206-0197 Date Claim number CS URGENT Reply Required Within 30 Days to Avoid Interruption of Your Payments For your protection, the Office of Personnel Management (OPM) is verifying your records to make sure the annuity payments and informational correspondence we send you are going to the right person and the correct address. If we are paying you as the survivor of a deceased Federal employee or retiree, it is your information we are verifying. The information for the deceased is already on file. Please take the following actions promptly: Verify the name and address shown above for accuracy (including spelling). Enter the information requested in Parts A or B on page 2 of this letter. Sign your name in the space provided. Return this letter to the Office of Personnel Management in the enclosed envelope. Thank you for your cooperation in this important matter. Retirement Inspection Branch 202-606-0249 Privacy Act and Public Burden Statements Solicitation of this information is authorized by the Civil Service Retirement law, Federal Employees Retirement law, the Federal Employees' Group Life Insurance Program, and the Federal Employees Health Benefits Program (Chapters 83, 84, 87, and 89 of 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 as an individual identifier to distinguish between people with the same or similar names. Failure to furnish information may delay or make it impossible for us to determine your eligibility to receive benefits. We estimate this form takes an average 10 minutes per response to complete, 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, Retirement and Benefits Publications Team (3206-0197), Washington, DC 20415-3430. The OMB Number 3206-0197 is currently valid. OPM may not collect this information and you are not required to respond, unless this number is displayed. Previous edition is not usable. RI 38-107 Revised August 2010 American LegalNet, Inc. www.FormsWorkFlow.com Part A - Annuitant's Response (If the annuitant is deceased, go to Part B.) If the annuitant cannot sign in Item 4, complete Items 1, 2, and 3 as applicable. Skip Item 4 and complete Item 5. Item 1 - (Check one block.) My name and correspondence address shown on the front of this notice are correct. (Complete items 2 and 4 or item 5.) My name and/or correspondence address shown on the front of this notice are not correct. (Complete items 2, 3, and 4 or item 5.) Item 2 - (Enter your identifying information.) Annuity claim number Item 3 - (Show the correct information.) Name Annuitant's Social Security Number Telephone number (including area code) Address Email address City, State, and ZIP Code Item 4 - Signature and Certification I hereby certify that the above information is true to the best of my knowledge and belief. Annuitant's signature (do not print) Date (mm/dd/yyyy) Warning: Any intentionally false statement made above or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001) Item 5 - If it is not possible for the annuitant to sign, provide the information requested below. Reason the annuitant cannot sign Printed name of person replying Address of person replying City, State, and ZIP Code Daytime telephone number of person replying (including area code) Relationship to the annuitant of person replying I hereby certify that the above information is true to the best of my knowledge and belief. Signature of person replying on behalf of the annuitant Date (mm/dd/yyyy) Warning: Any intentionally false statement made above or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001) Part B - Deceased Annuitant (If the annuitant has died, give the following information.) Date of death (mm/dd/yyyy) Place of death Include a copy of the death certificate. Signature Your printed name and address Date signed (mm/dd/yyyy) Telephone number (including area code) Page 2 of RI 38-107 Revised August 2010 American LegalNet, Inc. www.FormsWorkFlow.com