Standard Form 3102 2012-2022

We estimate providing this information takes an average of 15 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 SF 3102 including suggestions for reducing completion time to the 3206-0173 Washington D.C. 20415-3430. Standard Form 3102 Revised February 2012 Important - The filing of this form will completely cancel any Designation of Beneficiary under the Federal Employees Retirement System or under the Civil Service Retirement System you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries of any lump sum payable at your death. Designation of Beneficiary Federal Employees Retirement System Retirement System Form Approved OMB No* 3206-0173 Important Read all instructions before filling in this form A. Identification Name Last first middle Place an X in the appropriate box Date of birth mm/dd/yyyy An employee Retired or an applicant for retirement Social Security Number Former employee eligible for retirement in the future If you are retired give your claim number Department or agency in which presently employed or former department or agency Bureau Division I the individual identified above designate the beneficiary or beneficiaries named below to receive any lump-sum benefit which may become payable under the Federal Employees Retirement System FERS after my death including lump-sum death benefits which may become payable based on amounts contributed to the Civil Service Retirement System CSRS before I became covered by FERS* I understand that this designation of beneficiary cancels any previous FERS or CSRS designation of beneficiary and that it remains in effect until I cancel it in writing or I receive payment of my FERS retirement contributions. Location City state and ZIP code I direct unless otherwise indicated below that if more than one beneficiary is named the share of any beneficiary who may predecease me or who may be disqualified for any other reason shall be distributed equally among the stated beneficiaries or entirely to the survivor. If none of the beneficiaries are alive and eligible to receive payment when a lump-sum payment becomes payable this designation is void and payment will be made according to the order of precedence set by law. B. Information Concerning The Beneficiaries See Examples of Designations First name middle initial and last name of each beneficiary Date of designation mm/dd/yyyy Address Including ZIP code of each beneficiary Relationship to you Your signature Share to be paid to Total 100 C. Witnesses A witness is not eligible to receive payment as a beneficiary We the undersigned certify that this statement was signed in our presence. Signature of witness Receiving agency certification I have reviewed this designation and certify that the designated shares total 100 and that no witnesses are designated as beneficiaries.