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Get 2019 Form Ds 5026

FORM DS 5026 Statement of Entitlement to FSPS Annuity Supplement 2012 Calendar Year Income Full Name of Annuitant Last First Middle Social Security Number Personal E-Mail Address Date of Birth Address Telephone Number Please complete the following Signature Date Reflects income from 2012 wages or self-employment after date of retirement on a calendar year basis. Report income from the date you reached your Minimum Retirement Age to December 31 2012. Income for this purpose includes earnings after your date of retirement derived from employment in the public or private sector including WAE appointments income from Personal Services Contracts etc* Income for this purpose does not include salary earned before retirement annuity benefits Social Security or unearned investment income. If you did not have any wage or self-employment income during 2012 write none on the blank line. See chart below to determine your MRA. Minimum Retirement Age If you were born*. Before 1948 In 1948 In 1950 In 1953 thru 1964 Your MRA is. 55 and 2 months In 1966 In 1970 and after 56 and 10 months Return this completed form to U*S* Department of State HR Service Center Annuitant Services 1269 Holland Street Charleston SC 29405. You may also e-mail the completed signed form to HRSC state. gov or send by fax to 1-843-202-3807. If you have any questions please contact the HR Service Center at 1-866300-7419 toll free or via e-mail to HRSC State. gov* If you do not respond to the questionnaire by Monday January 14 2013 your FSPS Annuity Supplement will be terminated beginning with the payment you will receive on the first business day of the month in February. Report income from the date you reached your Minimum Retirement Age to December 31 2012. Income for this purpose includes earnings after your date of retirement derived from employment in the public or private sector including WAE appointments income from Personal Services Contracts etc* Income for this purpose does not include salary earned before retirement annuity benefits Social Security or unearned investment income. If you did not have any wage or self-employment income during 2012 write none on the blank line. See chart below to determine your MRA. If you did not have any wage or self-employment income during 2012 write none on the blank line. See chart below to determine your MRA. Minimum Retirement Age If you were born*. Before 1948 In 1948 In 1950 In 1953 thru 1964 Your MRA is. Minimum Retirement Age If you were born*. Before 1948 In 1948 In 1950 In 1953 thru 1964 Your MRA is. 55 and 2 months In 1966 In 1970 and after 56 and 10 months Return this completed form to U*S* Department of State HR Service Center Annuitant Services 1269 Holland Street Charleston SC 29405. 55 and 2 months In 1966 In 1970 and after 56 and 10 months Return this completed form to U*S* Department of State HR Service Center Annuitant Services 1269 Holland Street Charleston SC 29405. You may also e-mail the completed signed form to HRSC state. gov or send by fax to 1-843-202-3807. If you have any questions please contact the HR Service Center at 1-866300-7419 toll free or via e-mail to HRSC State.

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