US Office of Personnel Management
OPM FERCCA IMPLEMENTATION TEAM
1900 E Street NW, Room 4H28
Washington DC 20415

Re: Request for Waiver of under Section 2208 of FERCCA

Dear Sirs:

My name is _______________________________, my SS# is ________________________,

and my address is ____________________________________________________________.

My phone number is (Day) ______________________ (Eve) _________________________.

The name and address of my current or last Federal employer is:________________________ .

Their phone number is: __________________.

I was incorrectly placed in the ________________________________ retirement system on (date) _________________.

My retirement coverage was corrected to the ____________________________ retirement system on (date) _________________.

(OR)

My retirement coverage has not been corrected to the _____________________________ retirement system. (List any comments you may have)

I request waiver of $________ of my settlement or court-ordered payment that totaled $_______ and was made on ___/___/___. (Please explain why the waiver is necessary to fully compensate you for the coverage error.)

I request waiver of interest or other amount owed to OPM. (State why your election of a retirement plan under FERCCA does not fully compensate you for the error.)

Use appropriate closing:

I have attached copies of documents that support my case.

(Or)

I received a lump-sum settlement or court-ordered payment. A copy of the agreement or order is attached.

______________________________________ (Signature)

______________ (Date)