SF 3106 marked up 08

Form Approved:
OMB Number 3206-0170

Application For Refund of Retirement Deductions
Federal Employees Retirement System
To avoid delay in payment:
(1) Complete both sides of application in full; (2) Type or print in ink.

Federal Employees
Retirement System

1. Name (last, first, middle)

2. Date of birth (mm/dd/yyyy)

See the attached sheets for instructions and
information concerning your application for
refund of retirement deductions and a Privacy
Act Statement.
3. Social Security Number

4. List all other names you have used (including maiden name, if applicable.)
5. Address for mailing refund check (number and street, city, state and ZIP Code) - We cannot authorize payment if this address is erased or otherwise changed.
Telephone no. (including area code)

(

E-mail Address

)

6. List below all of your civilian and military service for the United States Government. Attach a continuation sheet with your name and Social Security Number if necessary.

Department or Agency
(Including bureau, branch, or division
where employed)

Location of Employment
(City, State and ZIP Code)
and Payroll Office Number
(if known)

Title of Position
(Indicate if the
position was civilian [c]
or military [m])

Indicate whether
retirement
deductions were
withheld from your
salary. (Check one)

Periods of Service
Beginning Date
(mm/dd/yyyy)

Ending Date
(mm/dd/yyyy)

Have you paid
deposit for any
period including
military service?
(Check one)

Not
Fully or
Withheld Withheld Partially

Not
Paid

7. Have you accepted any further employment with the Federal government or the Government of the District of Columbia (or arranged for such employment) to become effective within 31 days from the ending date of your last
period of service?
Yes, continue with item 8.
No, skip items 8, 9, and 10. Continue with item 11.
8. If you answered "Yes" to Item 7, are Federal Employees Retirement System or Civil Service Retirement System deductions being withheld from your salary during
9. Date of new appointment (mm/dd/yyyy)
(Expected date if not yet reemployed.)
such employment?
Yes
No
10. Department or agency, including bureau, or division, and location (City, State, ZIP Code) where you are (or will be) employed.

11. Are you now married? If "Yes," complete SF 3106A, Current/Former Spouse's Notification of Application for Refund of Retirement Deductions, or other required information described in this package.
No
Yes, list the name of your current spouse:
12. Have you been divorced?
Yes If your answer is "yes" and you have at least 18 months of creditable civilian service, complete an SF 3106A (attached) for each living former spouse to whom you were married for at least 9 months. List
No
the former spouses in the space given below.
Name of former spouse(s)

U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel
and Payroll Offices

NSN 7540-01-249-5576
3106-107

Continue on Reverse
(You MUST complete both sides of this application.)

Date of marriage
(mm/dd/yyyy)

Date of divorce
(mm/dd/yyyy)

SF 3106
Revised August 2008
Previous editions are not usable