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Get Instructions For Opm Y Adjustment Form

U.S. OPM Form opm-ri-20-120 Form approved OMB No. 3206-0245 Claim number CSA U.S. Office of Personnel Management Retirement Services and Management Group P. O. Box 45 Boyers PA 16017-0045 Attention Y-Adjustment Request for Change to Unreduced Annuity I am a retired Federal employee. U*S* OPM Form opm-ri-20-120 Form approved OMB No* 3206-0245 Claim number CSA U*S* Office of Personnel Management Retirement Services and Management Group P. O. Box 45 Boyers PA 16017-0045 Attention Y-Adjustment Request for Change to Unreduced Annuity I am a retired Federal employee. I elected a reduced annuity to provide a survivor annuity for. My marriage has ended please pay at my Give your spouse s full name. unreduced annuity rate. The reason my marriage ended is Spouse Died Divorce Annulment The date my marriage ended is I have enclosed Check one block below. A copy of the death certificate. A court-certified copy of my divorce decree including all property settlements. I understand that if I have self and family health benefits coverage I can change to self-only at any time. Change my coverage to self-only. Note Check this block only if you want to make the change. A former spouse is no longer a family member and is not eligible for coverage under your family enrollment. Signature do not print Date Name last first middle initial Telephone number including area code Public Burden Statement We think this form takes an average of 30 minutes per response to complete. Send comments regarding our estimate or any other aspect of this form including suggestions for reducing completion time to the Office of Personnel Management OPM Forms Officer 3206-0245 Washington D*C* 20415-7900. The OMB number 3206-0245 is currently valid* OPM may not collect this information and you are not required to respond unless this number is displayed* RI 20-120 June 2003. O. Box 45 Boyers PA 16017-0045 Attention Y-Adjustment Request for Change to Unreduced Annuity I am a retired Federal employee. I elected a reduced annuity to provide a survivor annuity for. My marriage has ended please pay at my Give your spouse s full name. I elected a reduced annuity to provide a survivor annuity for. My marriage has ended please pay at my Give your spouse s full name. unreduced annuity rate. The reason my marriage ended is Spouse Died Divorce Annulment The date my marriage ended is I have enclosed Check one block below. unreduced annuity rate. The reason my marriage ended is Spouse Died Divorce Annulment The date my marriage ended is I have enclosed Check one block below. A copy of the death certificate. A court-certified copy of my divorce decree including all property settlements. A copy of the death certificate. A court-certified copy of my divorce decree including all property settlements. I understand that if I have self and family health benefits coverage I can change to self-only at any time. I understand that if I have self and family health benefits coverage I can change to self-only at any time. Change my coverage to self-only. Note Check this block only if you want to make the change. A former spouse is no longer a family member and is not eligible for coverage under your family enrollment.

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