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Effective Date: 



Updated: 12/2010


To request information from the United States Office of Personnel Management (OPM) regarding the amount of an applicant/recipient's civil service benefits.


Number of Copies

The worker completes an original and one copy of Form H1243-FTI.


The worker mails the original to the U. S. Office of Personnel Management (the address is preprinted on the form) and keeps the duplicate in the case record. Attach Form 3, Authorization to Furnish Information (signed by the applicant, recipient or responsible person), to the original.

Form Retention

Retain copy in case record until completed original form is received.

Original Form H1243-FTI is kept in the case record for three years after the recipient's eligibility is denied.

Detailed Instructions

From — Enter the worker's name and local office mailing address.

Applicant/Recipient Information — Enter annuitant's or dependent's name, address and civil service retirement claim number. Enter the name of the payee, if not the annuitant.

Federal Tax Information — If the request is based on information obtained on an Automated System for the Office of Inspector General (ASOIG) Match Worksheet, check the Yes box. Do not include a copy of the ASOIG Match Worksheet with the request. If the request is not based on information obtained on an ASOIG Match Worksheet, check the No box.

The worker signs on Page 1, and enters the date and local office telephone number. The worker enters the Return Form To: information on Page 2. The OPM representative completes all others items on Page 2.