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This form, a Standard Form 52 (Request for Personnel Action), and a copy of military orders (if available) or compatible notification from the Military Unit must be completed and submitted to the Joint Force Headquarters-New York, Human Resources Office prior to entering Military Active Service for appropriate processing. Except for employees separating, military services less than 31 days need not submit the above items mentioned. Failure to provide all the requested information could lead to a delay in processing the action and also impact any benefit elections. You are required to initial all applicable blocks to indicate your elections and that you have read and understand your options/conditions. I. INDIVIDUAL INFORMATIONName: Phone Number: Email:Supervisor’s Name: Supervisor’s Phone Number: Supervisor’s .mil Email: II. USERRA ELECTION TYPE ABSENT – UNIFORMED SERVICE: This election places Technicians in approved/authorized absence in either a paid or non-paid status depending upon the leave you may choose to use. Choose this option if you expect to return to employment after military service with seniority rights to the position. SEPARATION – UNIFORMED SERVICES (SEPARATION - US): This election is a form of resignation, but allows you to retain USERRA protection, but not necessarily to your former position. Choose this option if you do not expect to return from military service. You must provide written notice of intent not to return to your technician position. (Note: A separation under this provision affects only the employee's seniority while gone; it does not affect his or her restoration rights.) (Reference 38 USC Chapter 43, Section 4316(b)(1)(a) & 5 CFR 353.106) This selection does not prevent you from applying for reemployment with the agency. NOTE: (1) You must provide Military Orders or compatible notification with this checklist or as soon as possible. (2) Effective dates of either USERRA elections must coincide with the effective date of and not prior to entering military service. AN EMPLOYEE CANNOT BE ORDERED TO RESIGN OR TO ELECT SEPARATION-US. HE/SHE MUST FREELY ELECT TO SEPARATE.Initials Select and Initial ONLY ONE option and include an effective date. SHAPE \* MERGEFORMAT I ELECT ABSENT – UNIFORMED SERVICE I elect to enter into Non-Pay status. I ELECT SEPARATION – US I elect to separate and understand I still retain USERRA protection.I am a temporary employee and understand that my reemployment rights are limited to the established not to exceed (NTE) date of my temporary appointment. If my election above is to be placed on Absent US, I understand that I will be terminated when my temporary appointment expires.III. LEAVE STATUS I wish to use the following accrued leave during my period of Absent US or prior to being separated from my technician position. The first working day after other leave is used (if other leave is used) will be the effective date of my LWOP (KG). If using leave sporadically throughout my LWOP my effective date of LWOP will be the date my military orders begin. You may elect to keep, use earned leave (Annual, Compensatory for travel, paid Military Leave, and Time Off Award) or receive a lump sum payment of any unused Annual Leave prior to your departure. Please attach most recent civilian LES.Initials FROM DATE TO DATE The Effective Date of my Military Orders is: I wish to use leave while on Military Orders: Regular Comp Time* *I understand that this leave must be used before any other paid leave. Military LeaveAnnual LeaveTime Off AwardTravel Comp TimeThe Actual Effective Date of my LWOP, after all leave is used, is: IV. Lump Sum Payment Lump Sum Payout Any unused Annual Leave can be paid out in a lump which will be on your last LES. Compensatory Time, Military Leave, and Time off Awards are automatically forfeited (if not used) and do not qualify as part of the lump sum payment. Therefore, it is highly encouraged to use them prior to the anniversary date you earned them or they will be removed and cannot be restored. ABSENT – UNIFORMED SERVICE members. If electing a lump sum payment of your Annual leave, Defense Finance and Accounting Services (DFAS) will provide a lump sum payment on your last Leave and Earning Statement (LES). SEPARATION – US members. You will automatically receive a lump sum payment paid out by DFAS, which will be on your last LES. Forfeiture of earned leave ABSENT – UNIFORMED SERVICE members. (1) A maximum of 240 hours of Military Leave can be conserved. Military Leave over 240 hours will be forfeited and cannot be restored. (2) A maximum of 240 hours of Annual Leave can be conserved. Annual Leave Over 240 hours will be forfeited, but can be restored upon request. (3) Compensatory Time and Time off Awards cannot be conserved nor restored and will be forfeited if not used within 1 year of earning them. Technician must show proof that they lost comp time due to deployment for future changes that may restore lost comp time to NG. SEPARATION – US members. If using earned leave, your separation effective date will be the last day of your earned leave. Otherwise: (1) Paid Military Leave, Compensatory Time, and Time Off Awards will be forfeited if not used prior to separation and cannot be restored. (2) Annual Leave – you will automatically receive a lump sum payment. Initials I ELECT TO RECEIVE a lump sum payment of any unused annual leave I ELECT NO lump sum payment of any unused annual leave. V. TECHNICIAN PAY ABSENT – UNIFORMED SERVICE members. You will have certain effects on any automated deductions, investments and/or garnishments such as normal employment benefits or investments (Health Benefits, Life Insurance, Thrift Savings Plan, and Loans) established on your technician pay will temporarily halt during your Non-Pay status and will be automatically restored upon your return to duty or during times when you are in Active Pay status (i.e. while using accrued leave, military leave, etc). If you have child support payments/garnishments established on your technician pay, you must ensure DFAS has a copy of the court order. DFAS contact number is (866) 859-1845. At any time while on Absent-US that any type of leave is used (i.e. annual leave, military leave, earned compensatory time off for travel, or sick leave) all normal deductions will automatically be deducted if sufficient funds are available. (i.e. if you elect to keep your FEHB coverage while on Absent-US, your normal FEHB premium will be either deducted from your pay or you will be indebted for that amount). The agency does not pay for your premiums when you enter an active pay status for any amount of time during a pay period. SEPARATION – US members. You will have your Technician Pay and all Employee Benefits such as automated deductions, investments and/or garnishments discontinued. You will receive a separation packet containing forms and directions informing you how to handle your former benefits and/or pay information. It is your responsibility to coordinate for or meet your deduction or garnishment requirements/obligations. To manage your pay information (i.e. Address, Direct Deposit, LES delivery, and Allotment information) you will need to access the DFAS My Pay Web Site at https://mypay.dfas.mil/mypay.aspx Initials I understand my absence or separation or use of leave will have certain effects on my Technician Pay.VI. RESERVIST DIFFERENTIAL Employing agencies must pay differential payments to eligible Federal civilian employees who are members of the Reserve or National Guard (hereafter referred to as "reservists") called or ordered to active duty under certain specified provisions of law. Federal agencies must provide a payment (a "reservist differential") equal to the amount by which an employee's projected civilian "basic pay" for a covered pay period exceeds the employee's actual military "pay and allowances" allocable to that pay period. If you are in support of contingency operations such as Bosnia, Iraqi Crisis, Kosovo, Enduring Freedom, Noble Eagle, and Freedom’s Sentinel you may be eligible to receive a “Reservist Differential” payment if your civilian “basic pay” normally exceeds the amount of your military pay during a pay period. You may receive a differential sum equal to the amount of your civilian salary to offset your military pay as long as you are in authorized Non-Pay status. Additional information can be found at http://www.opm.gov/reservist/.I am eligible for a RD payment. I will complete the Application for Reservist Differential Payment and forward it to my supervisor along with all required supporting documentation for their review.VII. FEDERAL EMPLOYEE’S GROUP LIFE INSURANCE (FEGLI) ABSENT – UNIFORMED SERVICE and SEPARATION – US members. FEGLI coverage will continue for up to 24 months in accordance with (IAW) the Department of Homeland Security (DHS) Appropriations Act 2008, Section 1102 as long as military service is for more than 30 days. FEGLI will continue for up to 12 months and 24 months on a contingency at no cost to you and will discontinue automatically. However, you may continue FEGLI for an additional 12 months if your military service is beyond 12 months. To qualify, you must pay both the employee and agency share of premiums for their Basic coverage, and pay the entire cost for any Optional insurance (there is no agency share) for the additional months of coverage. Failure to pay the premiums as specified will constitute a voluntary cancellation of your coverage, subject to the 31-day extension of coverage and the right to convert to an individual policy. FEGLI coverage can be decreased while on Absent-US. The decrease in coverage is only for the period of active duty beyond the first 12 months. The previous level of FEGLI coverage will be restored when the returned to duty action is processed. Employee will need to use SF 2817 to make an election. This election can be generated through EBIS HYPERLINK "https://hhs.benefitsinfo.net/login.aspx" https://hhs.benefitsinfo.net/login.aspx Additional information can be found at HYPERLINK "http://www.opm.gov/insure/life" www.opm.gov/insure/life. Required Documents: Complete SF 2823 Designation of Beneficiary, ensure signature and two witness signatures. If FEGLI becomes discontinued, it will automatically be restored upon your return to duty or reemployment.Initials I DO NOT HAVE FEGLI. SKIP TO PART VIII. I understand my FEGLI options and elect only ONE of the following:Initials I ELECT TO CONTINUE my FEGLI coverage for an additional 12 months at 100% of the cost. I will coordinate with the Human Resources Office for additional information. I ELECT HRO TO DISCONTINUE my FEGLI coverage after the initial 12 months of paid benefits. I ELECT TO CONVERT to a private individual policy. I will coordinate with the Human Resources Office for additional information.VIII. FEDERAL EMPLOYEE’S HEALTH BENEFITS (FEHB) All FEHB suspensions and/or termination effective dates must/will coincide with the date on or after and not prior to entering military service. All FEHB suspensions do not allow for a 31 day extension of coverage. However, all FEHB terminations allow for a 31 day extension of coverage. Reinstatement/Enrollment You have 60 days after returning to duty/reemployment to reinitiate/enroll in FEHB. It is the EMPLOYEE’s responsibility to do this upon RTD. Waiver Upon returning to duty/reemployment, you may waive FEHB reinstatement/enrollment due to military TriCare coverage. 24 Month Coverage You may also elect to retain FEHB for up to 24 months during your Non-Pay status/separation whether in support of Contingency Operations or not. After 24 months, your FEHB coverage will automatically terminate with no option to retain it, but are eligible to reinitiate/enroll in FEHB upon your return to duty/reemployment. Non-contingency Operations If you are entering military service for non-contingency operations such as Active Guard Reserve, Active Duty for Special Work, Military School, etc, you may continue FEHB for up to 12 months and pay the share of your premiums. If your military service goes beyond 12 months, you may continue your FEHB for an additional 12 months by paying 102 percent of the premium: (1) you pay your premium share, (2) the Government’s share, and (3) a 2 percent administrative fee. If electing to continue FEHB coverage you may pay the premiums on a current basis. Payments should include the member’s SSN and annotate USERRA FEHB payment on checks. Otherwise, ABSENT – UNIFORMED SERVICE members can elect to incur a debt and repay it upon return to duty. Make checks payable to: DFAS-Cleveland ATTN: J3DCBB/555 1240 E. 9th Street Cleveland, OH 44199 Contingency Operations If you are in support of contingency operations such as Bosnia, Iraqi Crisis, Kosovo, Enduring Freedom, Noble Eagle, and Freedom’s Sentinel your FEHB premiums (both the employee and government contributions) will be paid by the agency up to 24 months so long as you are/were: (1) Called, ordered to active duty (voluntarily or involuntarily) in support of contingency operation as defined in 10 USC, section 101(a)(1)(3); and(2) Placed in either ABSENT – UNIFORMED SERVICE or SEPARATION – US to perform active duty. (3) Serving on active duty for a period of more than 30 consecutive days. NOTE: Any pay period where you use any type of paid leave will result in the agency not paying for your share of the premium for that entire pay period. Initials I DO NOT HAVE FEHB. SKIP TO PART IX.I ELECT HRO TO SUSPEND my FEHB utilizing an SF2810 and will reinstate upon Return to Duty.NOT IN SUPPORT OF A CONTINGENCY OPERATIONI ELECT TO RETAIN FEHB and incur a debt. I ELECT TO RETAIN FEHB and pay on a continuing basis during my absence and will pay the premiums directly to DFASIN SUPPORT OF A CONTINGENCY OPERATIONI ELECT TO RETAIN FEHB. I am aware the agency will cover my FEHB premium not to exceed 24 months. IX. FEDERAL EMPLOYEES DENTAL and VISION INSURANCE PROGRAM (FEDVIP) FEDVIP is separate from FEHB and does mirror the same coverage stipulations. You may elect to continue FEDVIP coverage, cancel, or have it automatically terminated at the time you enter military service. Continued Coverage / Direct BillingABSENT – UNIFORMED SERVICE members. You may elect to continue FEDIVP coverage throughout the duration of your military service. After two consecutive pay periods in Non-Pay status, payment for FEDVIP coverage will no longer be electronically withdrawn. You will be directly billed by FEDVIP. Your bill must be paid by sending in a check payable to BENEFEDS for the amount due. Failure to do so may cause you to default on your coverage. Cancellations ABSENT – UNIFORMED SERVICE and SEPERATION – US members. You may cancel your FEDVIP so long as cancellation is effective the date of or after and not prior to entering military service. There is no stipulated time frame to cancel your coverage; therefore, if you forget to submit your cancellation request, your coverage is subject to automatic termination. There is no 30-day continuation of coverage once your coverage has been cancelled TerminationsABSENT – UNIFORMED SERVICE members. Failure to comply with FEDVIP’s Direct Billing procedures or to submit your cancellation request may cause your coverage to be automatically terminated. SEPARATION – US members. You will have your FEDVIP coverage automatically terminated on the day you are separated unless you elect to cancel at an earlier date. FEDVIP Contact You must contact BENEFEDS Customer Service by email at HYPERLINK "mailto:Service@BENEFEDS.com" Service@BENEFEDS.com or call (877) 888-FEDS (877-888-3337) to coordinate all payment requirements and/or cancellation requests. Additional information can be found at HYPERLINK "http://www.benefeds.com" www.benefeds.com. Initials I DO NOT HAVE FEDVIP. I understand my FEDVIP options and will contact the BENEFEDS Customer Service regarding my elections and optionsX. Military Buyback Members are eligible to make Military Deposits for military service which may be potentially creditable. In order to obtain federal retirement coverage for military service, members must submit their DD214(s) or orders so the HRO can complete an RI 20-97 (Estimated Earning During Military Service) form and submit to DFAS. Please save all LES’s for Actual Earnings and quicker processing of your Military Deposit (Buyback). Contact the Human Resources Office for additional information and/or to receive the form: Rachel Hewitt – HYPERLINK "mailto:rachel.a.hewitt4.civ@mail.mil" rachel.a.hewitt4.civ@mail.mil – (518) 786- 4681 Danica Apa – HYPERLINK "mailto:danicia.n.apa.civ@mail.mil" danicia.n.apa.civ@mail.mil – (518) 786 - 6123 I understand that I must pay a Military Deposit for this period of Military Duty to count towards my Retirement.XI. THRIFT SAVINGS PLAN (TSP) Contributions to Military TSP Accounts While on military duty, you may contribute to the TSP from your military basic pay, incentives, and bonuses. If deployed to a tax-exempt zone, all of the contributions made to TSP will be permanently tax-exempt. You must make your military election via MyPay or by submitting a TSP-U-1 to your military pay technician. Only contributions from your military basic pay will be counted towards the agency matching contributions upon your return to duty to your Technician position. Loan Information ABSENT – UNIFORMED SERVICE members. If you have TSP Loan(s), pay deductions will temporarily be frozen while in Non-Pay status. This will suspend your TSP loan payments until you return from service in the uniformed services. SEPARATION – US members. You will have any TSP loan deductions discontinued. You may contact the TSP Office at 1-TSP-YOU-FRST (1-877-968-3778) to make other payment arrangements. If the loan is not paid off within 90 days, it will become a taxable disbursement. For more information on the TSP, please visit the TSP website ( HYPERLINK "http://www.tsp.gov" www.tsp.gov) Initials I understand I may contribute to TSP from my Military Pay and can make the election via MyPayI HAVE ATTACHED MY MOST RECENT CIVILIAN LES FOR MY TSP LOANI DO NOT HAVE A TSP LOANXII. FLEXIBLE SPENDING ACCOUNTS (FSAFEDS)If enrolled, I must notify FSAFEDS at 1-877-372-3337 (prior to leaving for military service) regarding my entrance on military service (as well as my return to civilian duty). FSAFEDS will assist me with my options to either continue or cancel my FSA account(s). I understand that I must also contact FSAFEDS if I am eligible for a Qualified Reservist Distribution (QRD). For more information please visit their website at www.FSAFEDS.comI DO NOT HAVE AN FSAI DO HAVE FSA AND WILL CONTACT FSAFEDSXIII. OFFICE OF THE WORKER’S COMPENSATION PROGRAM (OWCP) This section helps HRO to identify Technicians who have sustained work related injuries during Technician status prior to and after military service. It identifies and removes military Line of Duty information conflicts with OWCP claims. Initials I have an open OWCP claim on file. Claim #: I have a closed OWCP claim on file. Claim #: I do not have an OWCP claim on file.XIV. FEDERAL LONG TERM CARE INSURANCE PROGRAM (FLTCIP)If enrolled, I understand that in order to continue my LTC insurance, I must keep my premium payments current to avoid cancellation of my coverage. I may not incur a debt. I understand that it is my responsibility to contact LTC Partners at 1-800-582-3337 (prior to leaving for military service) to discuss and/or change my payment option. If I change my payment option from payroll deduction, it is my responsibility to contact LTC Partners upon my return to civilian duty if I want to have the payroll deduction reinstated.I DO NOT HAVE FLTCIPI DO HAVE FLTCIP AND WILL CONTACT LTC PARTNERSXV. NGAUS I have the following NGAUS coverage, which I wish to continue or terminate as indicated below. I understand that if I elect to continue the coverage, I will be responsible for the premium cost after the waiver period (depending on the type of coverage) and /or direct-bill payments. You can contact NAGUS Customer Service at 1-800-537-5024. ContinueTerminateI DO NOT have NGAUSBasic and Supplemental DisabilityTechLifeGuardlife (Tech/Spouse)ValuLife (Tech/Spouse)Universal Life (Tech/Spouse)I hereby give my consent to the HRO to provide the NGAUS Administrator with a copy of my SF50 for the AUS action.I do not give my consent to the HRO to provide the NGAUS Administrator with a copy of my SF50 for the AUS action. I understand that failure to give my consent may impact life insurance benefits.XVI. BENEFICIARY FORMS When was the last time you checked your designations of beneficiary? Most employees and annuitants don't realize that they have several designations to keep current. If you don't have a designation on file, then the funds will be distributed according to the order of precedence. That may be OK with you, but maybe it isn't. Worse yet is an out-of-date designation giving the money to someone that you no longer wish to give it to. Please fill out a new beneficiary form for each fund and attach with your USERRA LWOP checklist: SF1152 – Unpaid Compensation SF2808 – CSRS SF2823 – FEGLI SF3102 – FERS TSP3 – Thrift Savings I HAVE FILLED OUT AND ATTACHED ALL APPLICABLE BENEFICARY FORMSXVII. EMPLOYEE AND SUPERVISOR USERRA TRAINING & BRIEFING CERTIFICATIONEmployees and supervisors are required to take annual USERRA training. The Office of Personnel Management (OPM) has approved USERRA training which is available online at: HYPERLINK "https://www.esgr.mil/Portals/0/Volunteer%20Resources/Training/USERRA/USERRA%20101_102_Training.swf?ver=2018-11-27-163555-160" https://www.esgr.mil/Portals/0/Volunteer%20Resources/Training/USERRA/USERRA%20101_102_Training.swf?ver=2018-11-27-163555-160 Upon completion, print certificate and submit with checklist. As part of the requirement that each employee be properly briefed on his/her USERRA rights, responsibilities and entitlements, each employee and his/her supervisor must certify that they have reviewed the information provided in this checklist as well as the OPM USERRA training and that they understand their rights, responsibilities and entitlements. An employee absent because of service in the uniformed services is to be carried on leave without pay unless the employee elects to use other leave or freely and knowingly provides written notice of intent not to return to a position of employment with the agency, in which case the employee can be separated. (Note: A separation under this provision affects only the employee's seniority while gone; it does not affect his or her restoration rights.) (Reference 38 USC Chapter 43, Section 4316(b)(1)(a) & 5 CFR 353.106) EMPLOYEE USERRA TRAINING CERTIFICATIONI have completed the mandatory OPM USERRA training and understand my rights, responsibilities, and entitlements under USERRA. If my unit has no HR Remote Designee assigned, I will complete the “Human Resource Remote Designee” section below. My USERRA certificate is attachedDate Signature SUPERVISOR USERRA TRAINING CERTIFICATIONI have reviewed the mandatory OPM USERRA training and understand my supervisory rights, responsibilities, and entitlements under USERRA and have properly counseled my employee accordingly. My completed USERRA training certificate is attached.Date Supervisor’s Title Supervisor’s Phone NumberDate Supervisor’s Signature Supervisor’s Email Address TECHNICIAN SIGNATUREI have read and understand my USERRA options, benefits, elections, and conditions. I have provided a copy of my LES to my HR Remote Designee as verification of my current benefits and deductions. SIGNATURE:Date:REMOTE DESIGNEE USE ONLYComplete/check off each item to verify completion: SF -52 attached Orders (compatible notification) attached Members LES to review all benefits, deductions and leave balances SF3102/2808, SF2823, SF1152, TSP-3 Designation of Beneficiary Member & Supervisors completed USERRA training certificatesCompleted by:HRO USE ONLYComplete and initial off each item to verify completion:Completed by:SF -52 attached Orders (compatible notification) attached Annual Leave Lump Sum (Y/N) Remedy Ticket Number: Signature/Date: Updated Beneficiary Forms Signed and UploadedFEHB code: For FEHB Terminations: DCPDS updated, SF 2810 FEGLI Code: TSP-41 Submitted Pay Status in DCPDS checked to ensure action flowed successfully No pay was used after the effective date of this action. 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laِpض(ےےےےےےےےےےےےےےےےyt%â$$Ifa$gd%âإZئZèZéZêZِِêê$$Ifa$gd%â $IfgdLإêZëZىZُZ/&& $IfgdLإذkd4.$$If–lضض\„T$ک+چCD ض tàض(ےےےےےےےےےےےےےےےےض0ےےےےےےِ“+ِضےےےےضےےےےضےےےےضےےےے4ض4ض laِpض(ےےےےےےےےےےےےےےےےyt%âُZِZ÷ZّZََ#ذkd1/$$If–lضض\„T$ک+چCD ض tàض(ےےےےےےےےےےےےےےےےض0ےےےےےےِ“+ِضےےےےضےےےےضےےےےضےےےے4ض4ض laِpض(ےےےےےےےےےےےےےےےےyt%â$$Ifa$gd%âّZùZ[[[ِِêê$$Ifa$gd%â $IfgdLإ[[[,[/&& $IfgdLإذkd.0$$If–lضض\„T$ک+چCD ض tàض(ےےےےےےےےےےےےےےےےض0ےےےےےےِ“+ِضےےےےضےےےےضےےےےضےےےے4ض4ض laِpض(ےےےےےےےےےےےےےےےےyt%â,[-[.[/[ََ#ذkd+1$$If–lضض\„T$ک+چCD ض tàض(ےےےےےےےےےےےےےےےےض0ےےےےےےِ“+ِضےےےےضےےےےضےےےےضےےےے4ض4ض laِpض(ےےےےےےےےےےےےےےےےyt%â$$Ifa$gd%â/[0[M[N[O[ِِêê$$Ifa$gd%â $IfgdLإO[P[Q[/#$$Ifa$gd%âذkd(2$$If–lضض\„T$ک+چCD ض tàض(ےےےےےےےےےےےےےےےےض0ےےےےےےِ“+ِضےےےےضےےےےضےےےےضےےےے4ض4ض laِpض(ےےےےےےےےےےےےےےےےyt%âQ[أ[ؤ[إ[‰\ِ`Tِ$$Ifa$gd%â–kd%3$$If–lض”Fض0„ک+( ض tàضےےےےےےےےض0ےےےےےےِ“+ِضےےضےےضےےضےے4ض4ض laِpضےےےےےےےےyt%â 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