Form Approved:

OMB No. 3206-0228

Documentation in Support of

Disability Retirement Application

This package contains the forms applicants for disability retirement from civilian Federal service need to complete.
You should have received with this package a pamphlet entitled: Information About Disability Retirement. If you did
not receive the information pamphlet, ask your agency to give you one. This package contains the following forms:
Standard Form 3112A, Applicant's Statement of Disability, Standard Form 3112B, Supervisor's Statement, Standard
Form 3112C, Physician's Statement, Standard Form 3112D, Agency Certification of Reassignment and
Accommodation Efforts, and Standard Form 3112E, Disability Retirement Application Checklist.

You should keep one copy each of the completed forms for your own records. Your agency will send the originals of
each form to the Office of Personnel Management (OPM). You must obtain the evidence that will enable OPM to
decide that your disease or injury is so severe that you can no longer perform useful or efficient service, or that you
have a medical condition that requires restrictions from critical duties of your job.

You can help speed the processing of your application. Make sure all the information requested on the forms is
provided. Put a copy of your position description with the forms you give your doctor(s). See that the information you
submit contains diagnosis, prognosis, and a treatment plan dated no more than 60 days before the date your
application is filed. Although we accept all medical evidence about your disease or injury, current evidence provides
the best support of your application.

If you are applying for disability retirement under the Federal Employees Retirement System (FERS) or the
Civil Service Retirement System (CSRS) with offset service, you must document that you have applied for Social
Security disability benefits. The application receipt or award notice that you receive when you apply for Social
Security benefits should be attached to your application. Your application cannot be completely processed without
this information. Important: If Social Security awards you benefits, your payments from OPM must be reduced
starting on the date the Social Security award started. Since this may result in an overpayment of OPM benefits, you
should not spend any of the money from Social Security until your annuity from OPM has been reduced and OPM
has billed you for any overpayment. OPM is required by law to collect any annuity overpayment. If any or all of the
overpayment cannot be repaid, OPM may have to start debt collection procedures.

If you are not separated from Federal Service, return all the completed forms and associated documents to your
agency's personnel office. Your personnel office will assemble your disability retirement application package and
send it to OPM. Please follow up with your agency to be sure they send your application to OPM.

If you have been separated from Federal service for more than 31 days, you need to give each form to the
appropriate individual and ask that the completed forms be returned to you so you can assemble your disability
retirement application package yourself and send it to OPM at:
U.S. Office of Personnel Management

Retirement Operations Center

P.O. Box 45

Boyers, PA 16017-0045

OPM must receive your application not more than one year after the date you separated from your position. If you are
unable to get all the information requested, do not delay submitting your Standard Form 3112A to OPM. See the
accompanying pamphlet for an explanation of exceptions.

Standard Form 3112

7540-01-385-7215 Revised May 2011
3112-103 Previous edition is usable
 Applicant's Statement of Disability
Civil Service In Connection With Disability Retirement Under the Civil Service Retirement System or Federal Employees

Retirement System the Federal Employees Retirement System Retirement System

A copy of this completed form must accompany the Supervisor's Statement you give
your supervisor(s). Form Approved:
OMB No. 3206-0228
1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social security number

4. Fully describe your disease(s) or injury(ies.) We consider only the diseases and/or injuries you discuss in this application.

5. Describe how your disease(s) or injury(ies) interferes with performance of your duties, your attendance, or your conduct.

6. Describe any other restrictions of your activities imposed by your disease or injury.

7a. What accommodations have you requested from your agency?

7b. Has your agency been able to grant your request? (Attach an explanation or any documentation that you have regarding accommodation.)
Yes No
7c. What is your current status with your agency?
In pay status; and working without accommodation. In leave without pay status.*
In pay status; and working with accommodation. Separated from service*
*If you are currently in a leave without pay status or separated from service, what job(s), if any, have you performed since going into this status?
Please explain the physical and/or mental requirements for this (those) job(s).

8. Give the approximate date you became disabled for your 9. Have you been 10. Give date of most recent hospitalization.
position (mm/yyyy). hospitalized for your From (mm/yyyy) To (mm/yyyy)
disease or injury as
described in item 4?

Yes No
11. Notice for FERS and CSRS Offset Applicants ONLY
Application for disability retirement under FERS or CSRS Offset requires an application for Social Security Disability Benefits. Final
processing at OPM cannot be completed without a copy of your Social Security application receipt or award notice.
11a. Have you applied for disability benefits from the Social Security 11b. Is the application receipt or award notice attached?
Administration?

Yes No Yes No

7540-01-385-7215 3112-103 Standard Form 3112A

U.S. Office of Personnel Management Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices Previous edition is usable
12. List physician(s), (name(s), address(es), and dates of treatment) from whom you plan to request Physician's Statements (SF 3112C). Attach an
additional sheet if you wish to list more physicians.
Name Address Date of Treatments

13. I certify that all statements made above are true to the best of my knowledge and
belief. I give my permission for the release of information about my service and
Applicant's Consent and Certification medical condition(s) (i.e., disease or injury) to authorized agency and OPM officials.
I have read and understand all of the information provided in the instructions to
this application.
WARNING: Any intentionally false statement in Signature (Do not print)
this application or willful misrepresentation
relative thereto is a violation of the law punishable
by a fine of not more than $10,000 or Date (mm/dd/yyyy) Daytime telephone number
imprisonment of not more than 5 years, or both.
(18 U.S.C. 1001) ( )
Email address

Privacy Act Statement

Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and by the Federal
Employees Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be used to identify records properly
associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or
future benefits, and to maintain a uniquely identifiable claim file. The information may be shared and is subject to verification, via paper,
electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social security
administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination or
continuation of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above, with
law enforcement agencies when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397
(November 22, 1943) authorizes the use of the Social Security Number. Furnishing the data requested is voluntary, but failure to do so
will delay or prevent action on the retirement application.

Public Burden Statement

We estimate this form takes an average 30 minutes per response to complete, including the time for reviewing instructions, getting the
needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including
suggestions for reducing completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team
(3206-0228), Washington, D.C. 20415-3430. The OMB number, 3206-0228, is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.

PRINT
SAVE Reverse of Standard Form 3112A
3112-103 CLEAR Revised May 2011
 Supervisor's Statement
In Connection With Disability Retirement Under the Civil Service Retirement System
Civil Service and the Federal Employees Retirement System Federal Employees
Retirement System Retirement System
This form should be completed by the immediate supervisor
or someone who is in a position to observe the applicant on a regular basis. Form Approved:
OMB No. 3206-0228

Instructions

All sections of this form must be completed properly. "Unsatisfactory conduct" means conduct for which an
Failure to do so will delay the processing of the disability employee may be removed or disciplined for cause under
application at OPM. adverse action procedures. (For example, discourteous
conduct to the public, behavior which poses a threat to the
The employee identified in Section A has indicated that he or life, health, safety, or well-being of co-workers, subordinates,
she intends to apply for disability retirement. The applicant's or the public.)
signature on the "Applicant's Statement" authorizes his or her
immediate supervisor (or a supervisor who was and is in a "Accommodation" means an adjustment made to a job and/or
position to observe the applicant on a regular basis) to provide work environment that enables a qualified handicapped person
the information and documentation requested. The immediate to perform the duties of that position. Reasonable accommo
supervisor is asked to provide information about the applicant's dation may include modifying the worksite, adjusting the
job, performance, attendance, and conduct. work schedule, restructuring the job, acquiring or modifying
equipment or devices, providing interpreters, readers or
If you need more space in any section, attach a separate sheet
personal assistants, and reassigning or retraining employees.
and indicate that an attachment is provided.
The following definitions apply to the terms used in the "5 CFR 531.409(d)" is the regulation that provides for a
Supervisor's Statement. waiver of the requirements for determination of an employee's
level of competence in certain cases when the employee was
"Less than fully successful performance" means performance in duty status for less than 60 days during the 52 calendar
of an employee which fails to meet established performance weeks before a within-grade increase would be due.
standards in one or more critical elements of the employee's
position or the equivalent level for a position not under CFR After completing and certifying this form and attaching the
430. appropriate documentation, you should return the original to the
"Critical element" means a component of an employee's job employee or to your personnel office according to instructions
that is of sufficient importance that performing below the and practices in your agency. In either case, a copy must be given
minimum standard established by management requires to the employee. Please do not send the form directly to OPM
remedial action, such as denial of within-grade increase, and unless OPM specifically requested you to do so.
may be the basis for reducing the grade level or removing the
employee. If necessary, you may be contacted by OPM for additional
information or clarification.
"Unacceptable attendance" means absence from work which
is too frequent, unpredictable, or lengthy to allow the job to be
done.

Section A - Applicant Identification

1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social security number

Section B - Information About Employee's Performance

(See instructions above)
1. Title of position of record. (Attach a copy of position description and current performance standards. 2. Date of entry into position
If available, attach a copy of the latest performance appraisal.) (mm/dd/yyyy)

3. Is performance less than fully successful in any critical element of position?

Yes, complete items 4 - 6 of this section. No, go to Section C.

4. Show the approximate date (mm/yyyy) 5. After the date in item 4, has the employee received a within-grade step 5a. Was within-grade
that unacceptable performance or the increase or an award based on performance of a critical element? increase granted under 5
inability to do the job began. CFR 531.409 (d)? (see
Period the increase or award covered. instructions)
Yes From (mm/yyyy) To (mm/yyyy)
No Yes No

3112-103 Original - To OPM Through Agency Channels Standard Form 3112B

U.S. Office of Personnel Management Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices Previous edition is usable
6. Identify any critical element(s) of the position which employee does not perform successfully or at all. Explain the deficiencies you observed.
Attach supporting documentation such as notice to the employee that performance is less than fully successful or physician's recommendation
regarding medical restrictions.

Section C - Information About Employee's Attendance

1. Has employee stopped coming to work?
No Yes, how long is absence expected to continue (if known)?
2. Is employee's attendance unacceptable for continuing in current position?
No Yes, attendance stopped or became unacceptable on (mm/yyyy):
3. Explain the impact of employee's absence on your work operations.

Annual Sick LWOP

4. How many hours of leave has employee used for apparent medical reasons since date in item
C2? (Attach copies of medical information on which you based your decision to approve Enter Leave
leave, leave records, records of contact with or notices to employee. Include as much Hours Used
information as possible about specific reasons for leave use.)

Section D - Information About Employee's Conduct

1. Is employee's conduct unsatisfactory?
No, go to Section E. Yes, conduct became unsatisfactory on (mm/yyyy):
2. Describe how conduct is unsatisfactory (attach supporting documentation, such as notice to employee of proposed adverse action).

Section E - Accommodation and Reassignment

(Consult with agency Coordinator for Employment of the Handicapped)
1. What efforts have been made to accommodate the employee in current position?

2. Has employee been reassigned to a new permanent position? (If yes, to what position and when?) 3. Has employee been reassigned to "light duty"
or a temporary position?
No Yes, to on (mm/yyyy): No, go to Section F. Yes
4. Describe the reason for temporary nature of assignment and length of time the employee is expected to occupy the position.

Section F - Supervisor's Certification

1. How long have you supervised the employee? 2d. Supervisor's office mailing address

2. I certify that all statements made on this Supervisor's

Statement are true to the best of my knowledge and belief.
2a. Supervisor's signature 2c. Date (mm/dd/yyyy) 2e. Supervisor's daytime telephone number (including area code)

2b. Supervisor's name (type or print legibly) 2f. Email address

PRINT SAVE CLEAR

Reverse of Standard Form 3112B
3112-103 Revised May 2011
 Physician's Statement
In Connection With Disability Retirement Under the Civil Service Retirement System
Civil Service
Retirement System and the Federal Employees Retirement System Federal Employees
Retirement System

Applicant must attach a copy of the most current position description

Form Approved:
OMB No. 3206-0228
Section A - Identifying Information and Consent
(to be completed by applicant)
1. Applicant's name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social security number

If you are currently employed by your agency or 4. Enter exact name and address (including ZIP Code).
separated for less than 30 days, enter exact name
and address including the name of the person or
office in your employing agency
where this information should be mailed.

If you have been separated from your

employing agency for 31 days or more
provide your current home address.

5. I authorize the release to the Office of Personnel Management and my employing agency of any
Applicant's Consent to Release and all information or records connected with my disability retirement application.
Medical Information Signature (do not print) Date (mm/dd/yyyy)

Privacy Act and Public Burden Statements

Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and the Federal Employees
Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your
application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a
uniquely identifiable claim file. The information may be shared and is subject to verification, via paper, electronic media, or through the use of
computer matching programs, with national, state, local or other charitable or social security administrative agencies in order to determine benefits
under their programs, to obtain information necessary for determination or continuation of benefits under this program, or to report income for tax
purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or potential
violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number. Furnishing the
data requested is voluntary, but failure to do so will delay or prevent action on the retirement application.

We estimate this form takes an average 60 minutes per response to complete, including the time for reviewing instructions, getting the needed data,
and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing
completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0228), Washington, DC
20415-3430. The OMB number, 3206-0228, is currently valid. OPM may not collect this information, and you are not required to respond, unless
this number is displayed.

Section B - Medical Documentation (to be completed by physician)

Instructions
The individual identified above is requesting medical documentation that will be evaluated, along with non-medical documentation,
in connection with his or her application for disability retirement from Federal Government service. Please include all objective
findings and reports concerning the individual's condition. This documentation may also be used in determining his or her eligibility
for reassignment to a position that he or she is medically able to perform. A copy of his or her position description is attached for
your information.

Please provide the medical documentation requested under "Medical Documentation Requirements" on your letterhead
stationery. It is important that you respond to every item listed. Enter the item number of the information requested and
provide your response. If an item is not applicable to the applicant's medical condition, enter "Not Applicable." Include in
your statement the identifying information in Section A, items 1 through 3, above. Your failure to provide complete infor
mation will delay the processing of your patient's disability retirement application.

Enclose your report and any attachments in a sealed envelope marked "Medical Disability - Privileged - Private." Please make
sure copies of all medical reports referenced in your statement are included. Send the envelope to the address shown in item 4
above. You may, if you wish, give it directly to the applicant for delivery to the appropriate office.
Continued on reverse

3112-103 Standard Form 3112C

U.S. Office of Personnel Management Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices Previous edition is usable
 Instructions (continued)
Please complete this statement within 2 weeks. Be sure to sign the report. Include your address and telephone number.

The applicant is responsible for any costs incurred in connection with providing this documentation.

Medical Documentation Requirements

You must provide the following information: disorders, provide the results of mental status examinations,
personality tests, test of cognitive function, educational
1. A comprehensive history of this patient's medical con evaluation, neuropsychiatric tests, etc.
dition(s). This must include detailed information regarding
the symptoms and history, past and current physical 3. Diagnosis of patient's condition(s). Preferably each
findings, results of laboratory studies and therapy of this diagnosis should be found in the current publication
condition(s). The medical documentation must contain "International Classification of Disease". In the case
specific information to show why this patient is not able to of psychiatric disorders, diagnostic titles and codes
perform his or her duties. The medical documentation from the DSM III(R) should be used.
should not be conclusory. Provide a discussion of patient
compliance with therapy, response to therapy, and plans for 4. An assessment of the degree to which the medical con
future therapy. Also, provide copies of pertinent hospital dition(s) has or has not become static and an estimate of
ization summaries and operative reports. the expected date of full or partial recovery or remission.
2. Copies of reports of all applicable diagnostic laboratory 5. If restrictions have been placed on this patient's activities,
tests (e.g. hematologic, chemistry, electrophysiologic, please state what they are, why they have been imposed,
radiologic, nuclear medicine, etc.) In the case of psychiatric and how long you expect these to be in effect.

General Information

Disability retirement determinations are made in accordance area at the same grade or pay level and tenure, for which the
with Federal retirement regulations. A person is entitled to employee is qualified for reassignment. Useful and efficient
disability retirement benefits only when the information service means fully successful performance of the critical or
submitted with the application shows that an employee is essential elements of the position (or the ability to perform at
unable to perform useful and efficient service because of that level) and satisfactory conduct and attendance.
disease or injury (1) in the employee's current position or (2)
within a vacant position, in the same agency and commuting

PRINT SAVE CLEAR

Reverse of Standard Form 3112C

3112-103 Revised May 2011
 Agency Certification of Reassignment and Accommodation Efforts
Civil Service In Connection With Disability Retirement Under the Civil Service Retirement System Federal Employees
Retirement System and the Federal Employees Retirement System Retirement System

Form Approved:
OMB No. 3206-0228

Instructions

The Coordinator for Employment of the Handicapped should The documentation supporting your response to item 4 must
review the Applicant's Statement, the Supervisor's Statement, include an assessment of the functional and environmental
the Physician's Statement, and any other relevant documen factors related to the employee's inability to perform at the fully
tation on file to determine if reasonable accommodation will successful level, unless there are no medical restrictions.
enable the employee to perform fully successful service in his
or her current position or whether a vacant position is available Reassignment (item 5) - Guidance related to reassignment of
in the agency, at the same grade or pay level in the same com an applicant for disability retirement is published in OPM's
muting area, for which the employee is qualified for reassign "CSRS and FERS Handbook for Personnel and Payroll
ment. Take special note of the Supervisor's Statement and Offices".
resolve any discrepancies between the information on that form
and this form. Telephone numbers for the applicant, the super After completing and certifying this form, please attach the
visor, and the physician may be found on their respective appropriate documentation and return the original to the
statements, should it be necessary to contact them for further employee or to your personnel office according to instructions
information. and practices in your agency. In either case, a copy must be
given to the employee. Please do not send the form directly to
If the employee is eligible to retire voluntarily, the employee OPM unless OPM specifically requested you to do so in this
should be advised of that fact. In general there is no difference case.
in the payment to a disabled annuitant and an optionally retired
annuitant, nor are there Federal tax advantages for a disability Your agency's obligation to continue to try to accomodate or
retiree. reassign the employee does not cease with the filing of this
certification. Your efforts should continue. If the accomm
All items must be completed. In items 4, 5, and 6, if you check odation or reassignment situation changes after the original
a box that requires additional explanation, please provide the filing of the certification, you must notify OPM of the changes.
explanation and/or attachment. This will enable us to process
the application without delay. OPM may contact you for additional information or
clarification.
Accommodation (item 4) - Guidance for determining reason
able accommodations may be found in 29 CFR 1614.203(c).

To be completed by Coordinator for Employment of the Handicapped or other authorized agency official.
See instructions at the top of this page
1. Name of applicant (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social security number

4. Has reasonable effort for accomodation been made? (You must check one statement below.)

No, the medical evidence presented to the agency shows that accommodation is not possible due to severity of medical condition and the
physical requirements of the position. (Attach copies of all medical evidence supporting the statement and explain why conditions prohibit
accommodation. Also, provide a detailed statement of the physical requirements of the position.) Employees should be counseled concerning
the following: The fact that your agency has determined accommodation to be unavailable due to status of a medical condition or due to
restriction imposed by a physician does not guarantee that OPM will reach the same decisions about the approval of a disability retirement
application.

No, the employee's condition does not appear to require accommodation. Medical information presented to agency does not document a
disabling medical condition.

Yes, describe below accommodation efforts made, attach supporting documentation and provide narrative analysis of any unsuccessful
accommodation efforts.

Continued on reverse
3112-103 Standard Form 3112D
U.S. Office of Personnel Management Duplicate - Employee's Copy Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices Previous edition is usable
5. Results of agency reassignment efforts (You must check one statement below.)

Reassignment is not necessary because employee's performance is fully successful and there are no medical restrictions which keep the
employee from performing critical duties or from attending work altogether.
Reassignment is not possible. There are no vacant positions at this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications standards.
The employee declined reassignment to a vacant position(s) in this agency at the same grade or pay level and tenure, within the same
commuting area, for which the employee meets minimum qualifications. (Attach a copy of any reassignment offers.)
The agency did not reassign the employee to the vacant position(s) in this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications. The position(s) identified and reason(s) for non-assignment are shown
below.
Position Title Reason for Non-Reassignment or Non-Selection*

* If the employee's medical condition precludes reassignment to the position, attach documentation. If the reason for non-selection is intended
removal, attach a copy of the removal notice to the employee.
6. Is the employee currently occupying a temporary position?

No, the employee is occupying a permanent position.

Not applicable, the employee is no longer an employee of the agency.

Yes, state below the nature of these duties, the reason for the temporary status, and length of time the agency expects the employee to occupy

this position.

Certification by Coordinator for Employment of the Handicapped or other authorized agency official.
7.
I certify that this statement is true to the best of my knowledge and belief.

7a. Signature of responsible agency official 7b. Title of responsible agency official 7c. Date (mm/dd/yyyy)

7d. Name of responsible agency official (type or print legibly) 7e. Telephone number (including area code)

7f. Email address

PRINT
SAVE
CLEAR

Reverse of Standard Form 3112D

3112-103 Revised May 2011
 Disability Retirement Application Checklist
For Disability Retirement Under the Civil Service Retirement System
Civil Service and the Federal Employees Retirement System Federal Employees

Retirement System (to be completed by employing agency) Retirement System

Form Approved: OMB No. 3206-0228

1. Name of applicant (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social security number

4. Do available records show that the employee has at least 5 years of civilian service under the Civil Service Retirement System or at least 18 months
under the Federal Employees Retirement System? Yes No
5. Will employee remain in duty status? 5a. Show the date pay stopped or will stop. (mm/dd/yyyy)

Yes
No
6. Has employee ever received or made application for compensation 6a. Claim number 6b. Period compensation was received.
from the Department of Veterans' Affairs? From (mm/yyyy) To (mm/yyyy)
Yes No

7. FERS and CSRS 7a. Has the employee made application for disability benefits from
7b. Is the application receipt or award notice attached?
Offset Applicants the Social Security Administration? Yes No Yes No
8. Are the following documents attached (Indicate by "X" for each). Not
Yes No Applicable
a. SF 2801 or SF 3107, Application for Immediate Retirement
b. SF 3112A, Applicant's Statement of Disability

c. SF 3112B, Supervisor's Statement

- Employee's Performance Standards

- Employee's Position Description

- Supporting documentation regarding employee's performance

- Supporting documentation regarding employee's leave use

- Supporting documentation regarding employee's conduct

d. SF 3112C, Physician's Statement (or equivalent)

e. SF 3112D, Agency Certification of Reassignment and Accommodation Efforts

- Supporting documentation of Agency's accommodation efforts

- Supporting documentation of employee's non-reassignment or non-selection

f. Agency report of Federal medical examination (if one was made)

g. Other:

9. Has the supervisor stated the employee's performance is less than fully successful in any critical element of the position in Section B, SF 3112B?

Yes, (1) a copy of the employee's performance appraisal covering the employee's service prior to the date shown in Section B,
item 5, of the Supervisor's Statement, and
(2) a copy of the performance appraisal covering service after that date, if available.
No
10. If the employee is temporarily at an address other than the one given 11. If the employee is unable to act on his own behalf, give the name
on SF 2801 or SF 3107, Section A (such as hospital, nursing home, and address of the person acting for him or her.
or with a relative), enter that address, including ZIP Code.

Agency Certification
12. 13. Full Agency name and address (including ZIP Code)
I certify that the information shown above accurately

reflects verified information in official records.

12a. Signature of Chief Personnel Officer or Designee

12b. Official title 14. List the full name and address of agency office and official to be
notified of OPM's determination (including telephone number and
area code).
12c. Email address

12d. Telephone number (incl. area code) 12e. Date (mm/dd/yyyy)

Check here if this address is the same as the address in item 13.
3112-103 Standard Form 3112E
U.S. Office of Personnel Management Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices PRINT SAVE CLEAR Previous edition is usable