Federal Employee Retirement Benefit Election Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Federal Agency

Current Position Title

Years of Federal Service

Planned Retirement Date

Date

Type of Retirement

Retirement Benefit Election

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry