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Effective Date: 10/2002
To request information from the United States Office of Personnel Management (OPM) regarding the amount of an applicant/recipient's civil service benefits.
Number of Copies
The worker completes an original and one copy of Form H1243.
The worker mails the original to the U. S. Office of Personnel Management (the address is preprinted on the form) and keeps the duplicate in the case record. Attach Form H0003, Authorization To Furnish Information (signed by the applicant, recipient, or responsible person), to the original.
Retain copy in case record until completed original form is received.
Original Form H1243 is kept in the case record for three years after the recipient's eligibility is denied.
From — Enter the worker's name and local office mailing address.
Applicant/Recipient Information — Enter annuitant's or dependent's name, address, and civil service retirement claim number. Enter the name of the payee, if not the annuitant.
Tax Sensitive Information — If the request is based on information obtained on an RG-101, check the "Yes" box. Do not include a copy of the RG-101 with the request. If the request is not based on information obtained on an RG-101, check the "No" box.
The worker signs on Page 1, and enters the date and local office telephone number. The worker enters the "Return Form To:" information on Page 2. The OPM representative completes all others items on Page 2.