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ATTN: FERCCA Team
P.O. Box 45
Boyers, PA 16017
Re: Request for Reimbursement of Out-of-Pocket Expenses
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) _________________.
My retirement coverage has not been corrected to the _____________________________ retirement system.
For Social Security taxes (FICA) and CSRS retirement deductions paid, please provide the amount paid and the agency to which payment was made.
For reimbursement of interest paid on a CSRS (Offset) deposit, please demonstrate why your election of CSRS (Offset) does not fully compensate you for the error.
For all other expenses, please show (1) amount paid, (2) to whom paid, (3) why you believe the expense resulted from the coverage error, and (4) how that course of action would have corrected/mitigated the effect of the coverage error.
Use appropriate closing:
I have attached copies of the necessary documents to prove my case (see the OUT-OF-POCKET EXPENSE Instructions to determine what proof is necessary).
I have attached proof that I have paid these expenses (see the OUT-OF-POCKET EXPENSE Instructions to determine what proof is necessary).
I received a lump-sum settlement or court-ordered payment. A copy of the agreement or order is attached.
I received an award or other payment to cover some or all of my attorney fees. A copy of the award or other document showing the details of the payment is attached.