Fed Benefits Data Questionnaire

Federal Benefits Data Collection Form

Please fill out this form and upload your documents and we will get in touch with you shortly.
Your Name *

First Name Last Name
Date of birth *

- Month - Day Year
Spouse Name

First Name Last Name
Spouse date of birth

- Month - Day Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
Your E-mail Address *
Retirement System *
If FERS transfer, transfer date

- Month - Day Year
CBPO transfer date

- Month - Day Year
Employee type
Retirement type
Regular= Traditional retirement (most people fall into this category, including LEO/FF/ATC leaving federal service prior to their respective mandatory retirement age (57/56), and those FERS retiring under “Minimum Retirement Age (MRA + 10”).

Optional= Offered an “Early out” because of reductions-in-force (RIF), or agency reorganization.

Mandatory= Special Provisions (LEO/FF/ATC) who wish to stay until forced to retire. Law Enforcement Officers & Firefighters must retire by age 57, and Air Traffic Controllers must retire by age 56.
Service computation date (SCD) *

- Month - Day Year
The SCD is the date used to determine retirement eligibility and used in the computation of the basic retirement annuity. This is not the same as the “SCD for Leave” typically found on the LES. The SCD only includes periods of service which someone contributed to the CSRS or FERS retirement system (i.e. a regular career appointment, military time which a deposit was made, non-deduction service for which a deposit was made, etc).
Annuity Creditable Service

Civilian Service (only use this column if there have been breaks in service) List any breaks in service, if applicable
Did you have any Military Service?
If YES Please list below from and to dates
Did you have part time work? (after 4/7/86)
If YES average hours per week
If YES average salary per year
Sick Leave Hrs to be Saved/Pay Period (Hrs - biweekly):
Sick Leave Saved To Date (Hrs) LES If unsure, you can estimate future hours to be saved based on how many potentially COULD have saved and how much ACTUALLY saved in the past. Could have saved: 30 yrs of svc X 26 pay periods per year X 4 hours earnable per pay period = 3120 hours; If you have only saved 1000 hours to date (roughly 1/3), you can assume that you will save 1/3 of future sick leave time.
Your Message
Annuity High Three Average

Typically, the salary on the LES includes base pay and locality pay for General Schedule employees in the 48 continuous states; You must also include Night differential and environmental pay for Wage Grade employees; Administrative Uncontrollable Overtime (AUO) and Law Enforcement Availability Pay (LEAP) for Law Enforcement; and Special Pay for Physicians and Dentists under Title 38 at the VA
Current Annual Salary $
Annuity Military Service (if applicable)
Do you have ACTIVE duty military service?

Yes No
If Yes from when to when?
Have you made a deposit for your active military service?

Yes No
Did you retire under an active duty military retirement?

Yes No
Do you have reserve military service?

Yes No
If yes From______To_________ (DD214)
Have you made a deposit for your reserve military service?

Yes No
Do you expect to retire under a reserve military retirement (Chapter 67, Title 10)?

Yes No
Annuity Deposit (Temporary Civilian Service)
Do you have any non-deduction (temporary time/casual) service?

Yes No
If Yes From _____________ To _____________________
Have you made a deposit for this service?

Yes No
Annuity Redeposit (Breaks in Civilian Service)
Did you ever have a break in service?

Yes No
If Yes From _____________ To _________________
Did you withdraw your annuity contributions?

Yes No
How much did you withdraw?
Date withdrawal received?

- Month - Day Year
Have you re-deposited these contributions?

Yes No
Annuity Annuity Calculation
Estimated High 3 Increase per year: % ESD Should be the same percentage entered on the High Three Form (Your Expected Annual Salary Increase (%) Each Year: %)
Annual Cost of Living Annuity Adjustment:
Survivor Benefit:

Yes No
Annuity Social Security – FERS Supplement
Are you eligible for Social Security at age 62?

Yes No
What is your Monthly Social Security Benefit at Age 62 $
Thrift Savings Plan ⇒⇒ Contributions
Percent of Salary to invest each pay check in your TSP: %
If you are making Catch-up Contribution, please put the per pay amount: $
Percent to invest in each fund: Where do future contributions go? (must total 100%)
Percent to invest in each L fund:
Percent to invest in each C fund:
Percent to invest in each F fund:
Percent to invest in each G fund:
Percent to invest in each I fund:
Percent to invest in each S fund:
Percent to invest in each L2020 fund:
Percent to invest in each L2030 fund:
Percent to invest in each L2040 fund:
Percent to invest in each L2050 fund:
Current Fund Balance: L FUND
Current Fund Balance: C FUND
Current Fund Balance: F FUND
Current Fund Balance: G FUND
Current Fund Balance: I FUND
Current Fund Balance: S FUND
Current Fund Balance: L 2020 FUND
Current Fund Balance: L 2030 FUND
Current Fund Balance: L 2040 FUND
Current Fund Balance: L 2050 FUND
What do you plan on doing with your TSP funds at retirement?

Monthly withdrawal Totally withdrawn Purchase Government Annuity Withdraw and invest for the highest lifetime income Other
Insurance ⇒⇒ FEGLI
FEGLI ELIGIBLITY

FEGLI coverage in retirement is only available if enrolled for either:

a) 5 full years prior to retirement date

b) the full period if employed less than 5 yrs, or

c) the full time equiv. of 5 yrs if some service was part time
What is your current FEGLI coverage?
Current FEGLI bi-weekly premium: $
Insurance ⇒⇒ FEHB
FEHB coverage in retirement is available when:

1) Must retire on an immediate annuity (can not defer annuity payments), and

2) Must be continuously enrolled under FEHB for 5 years of service immediately preceding retirement
Current Biweekly Health Insurance Cost: $
Average Annual Cost Increase: % (Trend is approx 8%)
Insurance ⇒⇒ Long Term Care
What LTC benefits do you currently have?
Do you currently have LTC benefits?

Yes No No but I am concerned about having in retirement.
Other
Do you and/or your spouse have an IRA, if so, what is the current value and where is it invested?
If you want us to include your spouse retirement income, please provide here. Retirement from work and Social Security. Please list and label.
Why are you requesting this report? What do you hope to gain from this report?
What are your top 3 concerns regarding your federal benefits in retirement?
Are you healthy?

Yes Yes but I Smoke No
Do you work with a Financial Advisor?

Yes No
Enter the message as it's shown *
Thanks for your submission. We will call you soon to review.
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Federal Benefits Data Collection Form

Annuity Social Security – FERS Supplement

Thrift Savings Plan ⇒⇒ Contributions

Insurance ⇒⇒ FEGLI

Insurance ⇒⇒ FEHB

Insurance ⇒⇒ Long Term Care

Other