Fillable Standard Form 3112a - Applicant'S Statement Of Disability printable pdf download

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

Revised May 2011

7540-01-385-7215

Previous edition is usable

3112-103

Standard Form 3112a - Applicant'S Statement Of Disability

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