Forms Index

 

Form
Number

Form Title

ELM Reference

CFC 100

CFC Pledge Card

617.42

DD 214

Certificate of Release or Discharge From Active Duty

512.232

CA–1

Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation

541.3, 542.111, 542.112, 542.21, 544.11, 544.12, 544.211, 544.212, 545.721, 545.724, 545.731, 545.75, 545.77, 547.51, 547.54, 821.121

CA–2

Notice of Occupational Disease and Claim for Compensation

541.3, 542.121, 542.21, 544.11, 544.12, 544.211, 544.212, 547.52, 821.121, 821.133

CA–2a

Notice of Federal Employee’s Recurrence of Disability and Claim for Pay/Compensation

541.3, 542.131, 542.21, 544.22, 545.722

CA–3

Report of Termination of Disability and/or Payment

525.148

CA–5

Claim for Compensation by Widow, Widower, and/or Children

541.3, 542.141, 542.21, 544.23, 821.123

CA–5b

Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren

541.3, 542.141, 542.21, 544.23

CA–6

Official Superior’s Report of Employee’s Death

541.3, 544.23, 821.123

CA–7

Claim for Compensation

525.141, 545.81, 545.82

CA–16

Authorization for Examination and/or Treatment

543.3, 544.12, 545.2, 545.21, 545.23, 545.44, 545.45, 545.5

CA–17

Duty Status Report

544.12, 545.52

CA–20

Attending Physician’s Report

525.141, 545.5

ES 931

Request for Wage Separation Information

551.422, 552.32, 552.51, 552.52, 553.13, 553.21, 553.23

ES 934

Request for Information or Reconsideration of Federal Findings

551.422, 552.42, 552.52, 553.22

ES 936

Request for Verification of UCFE Wage and Separation Information Furnished on Form ES 931

551.422, 552.52, 553.23

FE–6

Claim for Death Benefits (Federal Employees’ Group Life Insurance Program)

538.312, 538.33, 538.341, 567.31

FE–6 DEP

Statement of Claim

538.341

FE–7

Claim for Accidental Dismemberment

538.342

FE–8

Election of Living Benefits

534.4, 536.4

IRS Form W–4P

Withholding Certificate for Pension or Annuity Payments

589.52

OPM 1431

Spouse’s Consent to Survivor Election

564.24

OPM 1482

Agency Certification of Status of Reemployed Annuitant

537.131, 537.132

OPM 1528

Notification of Earnings for Medicare Eligibility

574.251

OSHA 2

Citation and Notification of Penalty

825.51, 825.6

OSHA 300

Log of Work–Related Injuries and Illnesses

812.32, 813.2, 813.31, 821.11, 821.122, 821.134, 821.141, 821.144, 821.4, 824.41, 825.441

OSHA 300A

Summary of Injuries and Illnesses

812.32, 813.2, 813.31, 821.134, 821.142, 821.144, 821.4, 825.441

OSHA 301

Injury and Illness Incident Report

821.11, 821.122, 821.143, 821.144

PS 50

Notification of Personnel Action

349.3, 354.23, 354.253, 365.213, 418.1, 421.516, 421.526, 422.155, 422.531, 422.831, 435.31, 495.48, 514.52, 519.233, 546.23, 552.41, 553.11, 553.12, 553.132, 935.211, 935.212, 935.262

PS 202

Health Benefits Refund Payment Authorization

525.132

PS 337

Clearance Record for Separated Employee

936.42

PS 820

Ranking of Position Request

212.2, 231, 232

PS 991

Application for Promotion or Assignment

354.242, 354.253

PS 999

Application for Reinstatement List

354.252, 354.271, 354.272

PS 1012

Travel Voucher

742.32

PS 1017–A

Time Disallowance Record

432.711

PS 1164

Claim for Reimbursement for Expenditures on Official Business

742.32

PS 1188

Cancellation of Organization Dues from Payroll Withholdings

925.11, 925.122, 925.5,

PS 1192

U.S. Savings Bond Authorization for Purchase and Request for Change

616.31

PS 1216

Employee’s Current Mailing Address

593.33, 665.5

PS 1221

Advanced Sick Leave Authorization

513.522

PS 1223–A

Earnings Statement

422.531, 422.831, 512.532

PS 1223–B

Earnings Statement – Net to Bank

422.531, 422.831, 924.71

PS 1224

Court Duty Leave – Statement of Service

516.23

PS 1314

Regular Rural Carrier Time Certificate

516.23

PS 1555

Statement of Account for CAGs H–L

868.133

PS 1723

Assignment Order

422.142

PS 1727

Award Recommendation/Authorization

495.47, 495.48

PS 1767

Report of Hazard, Unsafe Condition, or Practice

813.32, 814.1, 824.41, 824.61, 824.62, 824.631, 824.632, 824.633, 824.634, 824.635

PS 1769

Accident Report

821.11, 821.121, 821.123, 821.13, 821.131 821.131, 821.132821.142, 821.134, 821.144, 824.41, 825.441

PS 1772

Accident Log

824.41

PS 1773

Report of Hazard Log

824.634

PS 1783

On-the-job Safety Review/Analysis

821.22

PS 1902

Justification for Billing Accounts Receivable

452.11, 462.11, 743.43

PS 1961

Employee Uniform Allowance Statement

938.4

PS 2146

Employee’s Claim for Personal Property

641.52

PS 2240

Pay, Leave, or Other Hours Adjustment Request

452.11, 462.11, 594.5

PS 2246

Terminal Leave Worksheet

512.7

PS 2248

Monetary Payroll Adjustment

452.11, 462.11

PS 2342

Request: Unemployment Compensation Data

551.422

PS 2417

Confidential Statement of Employment and Financial Interests (for Use by Postal Service Employees)

662.2

PS 2432

Individual Training Progress Report

438.222, 732.11

PS 2485

Medical Examination and Assessment

546.621

PS 2488

Authorization for Medical Report

541.3, 545.5

PS 2489

Identification of Physical/Mental Disability

546.621

PS 2491

Medical Report – First Aid Injuries

541.3

PS 2548

Individual Training Record

732.13, 817.9

PS 2556

Third Party Statement of Recovery

541.3, 547.57, 547.7, Exhibit 547.57c

PS 2557

Employee’s Third–Party Recovery Statement

541.3, 547.58, 547.73, 547.74, Exhibit 547.58c, Exhibit 547.73

PS 2559

Third Party Claim – Information Request

541.3, 547.59b, Exhibit 547.59b

PS 2560

Referral of Third Party Material

541.3, 547.59, Exhibit 547.59d

PS 2562

Injury Compensation Program – Notice of Potential Third Party Claim

541.3, 547.55, 547.57, 547.58, 547.59, Exhibit 547.55

PS 2573

Request – OWCP Claim Status

541.3

PS 2577

Assignment of Claim to the USPS

541.3, 547.59, 547.72,
Exhibit 547.59c

PS 3074

Request for Waiver of Claim for Erroneous Payment of Pay

437.32, 437.4, 437.5

PS 3111

Specific Notice to Employees Entering (or Already in) Nonpay Status – Change in Health Benefits Regulations

525.222

PS 3189

Request for Temporary Schedule Change for Personal Convenience

516.33, 517.621

PS 3239

Payroll Deduction Authorization to Liquidate Postal Service Indebtedness

452.233, 452.243, 452.252, 452.334, 452.335, 452.336, 452.34, 453.22, 462.5, Exhibit 452.22, Exhibit 452.322

PS 3241

Statement of Receipts and Disbursements (Employee Social and Recreational Funds)

615.62, Exhibit 615.62

PS 3544

Post Office Receipt for Money

547.73

PS 3971

Request for or Notification of Absence

511.23, 511.42, 512.411, 512.412, 512.42, 512.421, 512.422, 513.331, 513.332, 513.34, 513.341, 513.342, 513.35, 514.51, 515.51, 516.33, 517.31, 517.621, 519.6, 519.742, 547.83

PS 3972

Absence Analysis

511.42, 513.393

PS 4584

Observation of Driving Practices

831.331

PS 4588

Observation of Work Practices — Delivery Services

812.52

PS 4589

Observation of Work Practices — General

812.52

PS 4943

Locker Record

612.241

PS 5900

Hiring Worksheet

344.1, 363.2

PS 6803

Wage and Separation Information

551.422, 552.32, 552.51, 553.13, 553.21, 553.221, 553.23

PS 6886

Thrift Savings Plan – Request for Retroactive Contributions

594.42, 594.43, 594.451, 594.46

PS 7314

Medical Agreement

868.131

PS 7381

Requisition for Supplies, Services, or Equipment

753.12, 753.3

PS 8006

Uniform Allowance Code Sheet (For Regular, Contract,
or Work Clothes Program)

935.212, 935.262, 938.4

PS 8201

Pre–Tax Health Insurance Premium Waiver/Restoration Form for Career Employees

524.832

PS 8202

Pre–Tax Health Insurance Premium Election/Waiver Form for Noncareer Employees

524.833

PS 8214

Certificate of OSHA, Safety, and Environmental Records Transfer

811.42

RI 76–10

Assignment of Federal Employees’ Group Life Insurance

534.5, 536.5

SF 8

Notice to Federal Employees About Unemployment Insurance

552.41, 553.12, 553.21

SF 180

Requests Pertaining to Military Records

512.232

SF 278

Financial Disclosure Report for Executive Branch Personnel

662.2

SF 813

Verification of a Military Retiree’s Service in Nonwartime Campaigns or Expeditions

512.232

SF 1150

Record of Leave Data

512.811, 512.812

SF 1152

Designation of Beneficiary – Unpaid Compensation of Deceased Civilian Employee

432.821

SF 1153

Claim for Unpaid Compensation of Deceased Civilian Employee

567.31, 567.334

SF 1187

Request for Payroll Deductions for Labor Organization Dues

924.11, 924.12, 924.4, 924.5, 924.72, 925.121, 925.122, 925.21, 925.5

SF 2800

Application for Death Benefits

567.31, 567.32, 567.33

SF 2801

Application for Immediate Retirement

562.352, 564.31

SF 2802

Application for Refund of Retirement Deductions

565.462, 565.514, 565.523

SF 2803

Application to Make Deposit or Redeposit

565.23

SF 2804

Application to Make Voluntary Contributions

565.41

SF 2806

Individual Retirement Record

525.149

SF 2809

Employee Health Benefits Election Form

521.613, 521.723, 521.73, 523.1, 523.2, 523.33, 523.4, 523.61, 523.632, 524.12, 524.32, 524.531, 524.542, 524.62, 524.64, 524.71, 524.921, 524.922, 524.95, 525.222, 525.233, 525.322, 525.422, 525.423, 525.454, 525.7, 526.322, 526.512, Exhibit 525.142, Exhibit 525.422

SF 2810

Notice of Change in Health Benefits Enrollment

521.613, 521.73, 523.632, 524.534, 524.542, 524.722, 524.73, 524.772, 524.773, 524.962, 524.966, 525.144, 525.145, 525.146, 525.222, 525.322, 525.422, 525.423, 525.441, 525.512, Exhibit 525.142, Exhibit 525.422

SF 2811

Transmittal and Summary Report to Carrier

526.52

SF 2817

Life Insurance Election (FEGLI)

534.343, 534.6, 535.113, 535.122, 535.124, 535.21, 535.22, 535.23, 535.24, 535.3, 535.51, 535.52, 535.611, 535.612, 535.63, 535.81, 535.831, 535.832, 535.911, 535.921, 537.132, 537.144, 539.11

SF 2818

Continuation of Life Insurance Coverage as a Retiree or Compensationer

534.343, 536.112, 536.211

SF 2819

Notice of Conversion Privilege – Federal Employees’ Group Life Insurance Program

534.341, 535.63, 535.722, 535.73

SF 2821

Agency Certification of Insurance Status

534.341, 535.63, 535.722, 537.172, 538.312, 538.322, 538.33, 539.12

SF 2822

Request for Insurance (FEGLI)

535.82, 535.831, 539.14

SF 2823

Designation of Beneficiary

534.343, 537.321, 538.111, 538.121, 538.124, 538.131, 538.16, 538.18, 539.13

SF 3102

Designation of Beneficiary – Federal Employees’ Retirement System

587.32

SF 3104

Application for Death Benefits

587.61, 587.62

SF 3106

Application for Refund of Retirement Deductions

585.51

SF 3107

Application for Immediate Retirement

582.78

SF 3107–2

Spouse’s Consent to Survivor Election

584.28

SF 3108

Application to Make Service Credit Payment

585.35

TSP–1

Thrift Savings Plan Election Form

591.36, 591.51, 591.53, 595.2

TSP–3

Designation of Beneficiary

597.41

TSP–9

Change of Address for Separated Participant

597.62

TSP–16

Exception to Spousal Requirements

597.62

TSP–17

Information Relating to Deceased Participant

597.62

TSP–19

Transfer of Information Between Agencies

591.35

TSP–20

Thrift Savings Plan Loan Application

596.31, 596.32, 596.56

TSP–21–R

Residential Loan Documentation

596.32

TSP–30

Interfund Transfer Request

591.42

TSP–70

Request for Full Withdrawal

597.22

TSP–70–T

Transfer Information

597.62

TSP–75

Age–Based In–Service Withdrawal Request

597.32

TSP–76

Financial Hardship In–Service Withdrawal Request

597.32

WH 380-E

FMLA Certification of Health Care Provider for Employee’s Serious Health Condition

512.412, 513.332, 515.52

WH 380-F

FMLA Certification of Health Care Provider for Family Member’s Serious Health Condition

512.412, 513.332, 515.532

WH 381

FMLA Notice of Eligibility and Rights and Responsibilities

512.412, 513.332

WH 384

FMLA Certification for Qualifying Exigency for Military Family Leave

512.412, 515.535

WH 385

FMLA Certification for Serious Injury or Illness of Covered Servicemember — for Military Family Leave

512.412, 515.532