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Get Application To Make Service Credit Payment Form Approved Omb No

Y. 2. Type or print in ink. 3. Complete Part A in full. If you are currently a Federal employee, have your employing agency complete Part B. Federal Employees Retirement System Part A. To be Completed by the Applicant 1. Name (Last, first, middle) 2. List other names you have used 3. Birthdate (mm/dd/yyyy) 4. Address (Number and street) 5. Department or agency in which presently or last employed, including bureau, branch, or division 6. Social Security Number (City, state and ZIP Cod.

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