Get Spousal Consent Form

Attachment to SF 2801-2 Spouse s Consent to Survivor Election Part 1 To Be Completed by the Current Spouse of Retiring Employee I have freely consented to the survivor annuity election described on the attached SF 2801-2 Spouse s Consent to Survivor Election. I understand that I will not be eligible to continue coverage based on my spouse s enrollment in the Federal Employees Health Benefits FEHB Program if my spouse dies because I have consented to his/her election to provide no survivor annuity. I understand however that consenting to no survivor annuity does not affect my right to continue FEHB if I am eligible to do so based on my own employment. If I am covered under my spouse s self and family enrollment at the time of his/her death and I am an employee eligible for FEHB coverage I may enroll within 60 days of my loss of coverage due to my spouse s death. a retiree who met the requirement of having been enrolled or covered under the FEHB Program for the 5 years immediately preceding my retirement or since my first opportunity I may enroll within 60 days of my loss of coverage due to my spouse s death. Name Type or print Signature Do not print Date Authorized to Administer Oaths I certify that the person named in Part 2 presented identification or was known to me gave consent signed or marked this form and acknowledged that the consent was freely given in my presence on this Theday of 20 at Month SEAL Year Signature City and State Expiration date of commission if Notary Public. I understand however that consenting to no survivor annuity does not affect my right to continue FEHB if I am eligible to do so based on my own employment. If I am covered under my spouse s self and family enrollment at the time of his/her death and I am an employee eligible for FEHB coverage I may enroll within 60 days of my loss of coverage due to my spouse s death. If I am covered under my spouse s self and family enrollment at the time of his/her death and I am an employee eligible for FEHB coverage I may enroll within 60 days of my loss of coverage due to my spouse s death. a retiree who met the requirement of having been enrolled or covered under the FEHB Program for the 5 years immediately preceding my retirement or since my first opportunity I may enroll within 60 days of my loss of coverage due to my spouse s death. a retiree who met the requirement of having been enrolled or covered under the FEHB Program for the 5 years immediately preceding my retirement or since my first opportunity I may enroll within 60 days of my loss of coverage due to my spouse s death. Name Type or print Signature Do not print Date Authorized to Administer Oaths I certify that the person named in Part 2 presented identification or was known to me gave consent signed or marked this form and acknowledged that the consent was freely given in my presence on this Theday of 20 at Month SEAL Year Signature City and State Expiration date of commission if Notary Public. I understand however that consenting to no survivor annuity does not affect my right to continue FEHB if I am eligible to do so based on my own employment. If I am covered under my spouse s self and family enrollment at the time of his/her death and I am an employee eligible for FEHB coverage I may enroll within 60 days of my loss of coverage due to my spouse s death. a retiree who met the requirement of having been enrolled or covered under the FEHB Program for the 5 years immediately preceding my retirement or since my first opportunity I may enroll within 60 days of my loss of coverage due to my spouse s death. .