Checklist for Civilian Employees Entering Active Duty under USERRA 1. Instructions This checklist provides important information regarding your benefits. You are required to initial all applicable blocks to indicate your elections and that you have read and understand your options/conditions. Please do the following: Fill in the blanks or initial as appropriate for each item listed below. Sign, date, and provide all pages of this document with military orders to your CPAC and Supervisor within 31 days of the date you enter on active duty. Retain a copy of your military orders and this form for your own records and future reference. You are encouraged to contact the Army Benefits Center-Civilian (ABC-C) to discuss the impact of Absent-US on your Federal Employees Health Benefits (FEHB) and other benefits. You can visit the ABC-C s web site at www.abc.army.mil for more information. You may also speak with a benefits specialist by calling 1-877-ARMY-CTR (1-877-276-9287) (overseas numbers can be found on the web site). 2. Individual Information Name: SSN: Pay Plan-Series-Grade: Street Address: City: State: Zip: Phone Number where you may be reached: Email where you may be reached: Contact Person in case you cannot be reached: Relationship Has Power of Attorney? Yes / No Street Address: City: State: Zip: Phone Number: Alternate Phone Number: 3. USERRA Election Type The effective date of my orders is (date reporting): I ELECT ABSENT UNIFMED SERVICE Select and Initial either the Absent-US Separation-US option and include an effective date. ABSENT UNIFMED SERVICE SEPARATION US I ELECT SEPARATION US. I am FREELY electing to separate and understand I still retain USERRA protections. Leave Elections Effective Date: Effective Date: I understand that I can use annual leave, military leave, earned compensatory time off for travel, and sick leave (if appropriate) while on Absent-US but must coordinate my requests with my supervisor and the timekeeper. An employee will receive a lump-sum payment for any unused annual leave when he or she separates from Federal service or enters on active duty in the armed forces and elects to receive a lump-sum payment. Generally, a lump-sum payment will equal the pay the employee would have received had he or she remained employed until expiration of the period covered by the annual leave. Contact your local CPAC regarding calculation of lump-sum payment and the impact of a lump-sum payout. I want my annual leave to remain to my credit. I want to be paid a lump sum for my annual leave balance. 4. REPTING BACK TO WK I understand my responsibility to return to work within the required time limitations: Service of 1 to 30 days - Must report the first regularly scheduled work day following completion of uniformed service. Service of 31 to 180 days - Must report no later than 14 calendar days after completion of uniformed service. Service of 180 or more days - Must report no later than 90 calendar days after completion of uniformed service. I understand it is my responsibility to contact my Supervisor to coordinate a physical return to duty date prior to my return to work. 1 of 5 July 2018 V1.5
5. FEDERAL EMPLOYEE S HEALTH BENEFITS (FEHB) Note: You must contact your CPAC or HRO as soon as you return to your civilian position. It is the employee s responsibility to ensure that their FEHB coverage and premiums are correct on their Leave and Earnings Statement (LES) and report any discrepancies within 2 pay periods of returning to duty. For additional information on FEHB please see www.abc.army.mil I have reviewed my leave and earnings statement and I do NOT have FEHB. Skip to Section 6. I understand my FEHB conditions and elect ONE of the following options: I want to terminate my FEHB coverage. I understand I will have FEHB coverage up until midnight the day before my Absent-US/Separation-US is effective. As of the effective date of my Absent-US/Separation-US (12:01 AM), I will not be covered by FEHB. I understand that my agency is required to automatically reinstate my coverage on my return to duty date unless I submit a waiver of reinstatment immediately upon my return. Proceed to Section 6. My military service is for 30 days or less My coverage will continue. I do not need to make any further elections regarding health benefits, unless my military service is later extended past 30 days. If extending beyond 30 days I will provide a revised checklist. Proceed to Section 6. I elect to retain my current FEHB coverage and will initial the appropriate box below for non-contingency or contingency operations (Must complete the below section for Contingency or Non-Contingency). Choose Option A or B below: OPTION A: MILITARY SERVICE NOT IN SUPPT OF A CONTINGENCY OPERATION I elect to retain FEHB by incurring a debt to be paid upon my return to civilian duty (on a pre-tax basis if I participate in Premium Conversion) for the first 12 months. After the first 12 months, my share will be 102% of the cost and it must be paid on a current basis. I elect to retain FEHB by making current payments on a continuing basis during my absence (with after-tax monies). After the first 12 months, I will pay 102% of the cost on a current basis. OPTION B: MILITARY SERVICE IN SUPPT OF A CONTINGENCY OPERATION ONLY I elect to retain FEHB. My agency will pay my share of the FEHB premiums for up to 24 months. The 24 month period starts the day I am placed on Absent-US (12:01 AM). 6. TRANSITIONAL TRICARE Select and Initial Acknowledgement: Upon my return to my civilian position I will notify my employing office if I want to waive reinstatement of FEHB coverage due to having transitional TRICARE coverage. 7. PREMIUM CONVERSION Select and Initial Acknowledgement: I understand that if I am participating in Premium Conversion, I have 60 days from the start of my unpaid leave of absence (Absent-US) to waive that participation, which would allow me to cancel my FEHB coverage at any time later. If I do not waive my premium conversion within the 60-day limit, I cannot later cancel my FEHB except during the annual FEHB open season or within 60 days after another Qualifying Life Event (QLE). For more information and the Premium Conversion Waiver form I can visit www.abc.army.mil. 8. FEDERAL EMPLOYEES DENTAL and VISION INSURANCE PROGRAM (FEDVIP) I have reviewed my leave and earnings statement and I do NOT have FEDVIP coverage. Skip to Section 9. I understand that in order to continue my FEDVIP enrollment, 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 a BENEFEDS Representative at 1-877-888-3337 to arrange accelerated deductions and to discuss and/or change my payment option. I also understand that if I change my payment option from payroll deduction, I must contact BENEFEDS on return to civilian duty if I want payment by payroll deduction reinstated. 2 of 5 July 2018 V1.5
9. FEDERAL EMPLOYEE S GROUP LIFE INSURANCE (FEGLI) Select and Initial ONLY ONE option: I have reviewed my leave and earnings statement and I do NOT have FEGLI. Skip to Section 10. I currently have FEGLI and acknowledge the following: I understand that my Federal Employee s Group Life Insurance (FEGLI) coverage will continue for 12 months in non-pay status (Absent-US) at no cost. P.L. 110-181 now allows employees to continue their FEGLI enrollment for an additional 12 months, for a total of 24 months. Employees will pay both employee and agency share of the premiums for basic and any Optional insurance after the first 12 months. If I separate from employment, my FEGLI coverage will continue at no cost for up to 12 months or until 90 days after my military service ends, whichever date comes first, and then my coverage terminates with an automatic 31-day free extension of coverage and the right to convert to a private policy. If I have a QLE while on Absent-US, such as marriage, divorce, death of spouse, acquiring an eligible child, I must contact my employing agency no later than 60 days after the event if I wish to elect or increase Options B and/or C coverage as appropriate for the QLE. Option B is effective the first day the employee returns to pay and duty status. Option C is effective the date of the event, if reported during the required time frame and before the coverage terminates after 12 months. FEGLI Elections - Insurance Choices After 12 Months on Active Duty I elect to terminate my FEGLI coverage at the end of 12 months in nonpay status, subject to a 31-day extension of coverage and the right to convert to an individual policy. I understand that the coverage will be reinstated automatically upon my return to work in pay and duty status in a FEGLI-eligible position. I elect to continue my FEGLI coverage for an additional 12 months after completion of my first 12 months in nonpay status. By choosing to continue coverage I agree to pay the applicable premiums, both the employee and the agency share for Basic coverage and the full premium for any Optional coverage, for each additional month after the first 12 months in nonpay status. My failure to pay the premiums on a bi-weekly basis within the required timeframe (FEGLI coverage will terminate after two consecutively missed payments) will constitute a voluntary cancellation of my coverage, subject to the 31-day extension of coverage and the right to convert to an individual policy. I elect to continue and reduce my FEGLI coverage for an additional 12 months after completion of my first 12 months in nonpay status. By choosing to reduce my FEGLI coverage I agree to pay the applicable premiums, both the employee and the agency share for Basic coverage and the full premium for any Optional coverage, for each additional month after the first 12 months in nonpay status. My failure to pay the premiums on a bi-weekly basis within the required timeframe (FEGLI coverage will terminate after two consecutively missed payments) will constitute a voluntary cancellation of my coverage, subject to the 31- day extension of coverage and the right to convert to an individual policy. A letter must accompany this form outlining the FEGLI coverage that you would like to become effective after your initial 12 months. NOTE: New FEGLI Election Opportunity is only available for civilian employees deployed in support of a Contingency operation and employees designated as Emergency Essential. 10. THRIFT SAVINGS PLAN (TSP) I understand that if I am restored to my civilian position under USERRA, I may make retroactive TSP contributions and elections, including missed catchup contributions, if otherwise eligible. I understand that I will need to contact ABC-C within 60 days of return to civilian duty to elect to make retroactive TSP contributions and elections. I understand that my retroactive contributions and elections will be reduced if I contributed to TSP as a uniformed service member while on active duty. I understand that if I contribute to my uniformed services TSP account while on active duty, I am responsible for providing ALL my military LES forms as documentation of those contributions. NOTE: The TSP 1% automatic agency contributions are payable regardless of whether or not you make up missed TSP contributions. I DO / DO NOT (CIRCLE ONE) have a TSP loan. TSP Loans I request that my employing office notify TSP of my non-pay status under USERRA so that my loan payments will be suspended. I understand that I cannot make a loan payment to my civilian account as a deduction from my military pay, and that the interest will accrue while my loan payments are suspended. I also understand that I must notify my employing office immediately upon return to civilian duty so they can notify TSP of the same, in order to avoid a taxable distribution. 3 of 5 July 2018 V1.5
11. FEDERAL LONG TERM CARE INSURANCE PROGRAM I have reviewed my leave and earnings statement and I am NOT enrolled in FLTCIP. Skip to Section 12. 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 a LTC Representative at 1-800-582-3337 to discuss and/or change my payment option. I also understand that if I change my payment options from payroll deductions, I must contact a LTC Representative on return to civilian duty if I want payment by payroll deduction reinstated. 12. FLEXIBLE SPENDING ACCOUNTS I have reviewed my leave and earnings statement and I am NOT enrolled in FSAFEDS. Skip to Section 13. I am aware that I must notify FSAFEDS of my entrance on Absent-US as well as upon return to duty by calling 1-877-372-3337. I understand that I may contact FSAFEDS to accelerate my pre-tax deductions prior to entering Absent US status. No contributions will be deposited into my account during my absence. I understand that if I decide to separate from civilian service, my FSA will terminate as of the date of my separation. There are no extensions. Any health care expenses incurred prior to the date of separation will still be reimbursable but those incurred after the date of separation are not reimbursable. This section is only for members of the Army National Guard, Army Reserve, Naval Reserve, Marine Corps Reserve, Air National Guard, Air Force Reserve, and Coast Guard Reserve. I am a reservist and I understand that under the Heroes Earnings Assistance and Relief Tax (HEART Act), reservists may receive a taxable distribution of their unused healthcare flexible spending account balance known as a qualified reservist distribution (QRD). I understand that the return of funds (QRD) is taxable income in the year that the funds were received and that there is a time limit to request a QRD beginning with the date of the orders and ending on the last day of the FSAFEDS grace period (2.5 months). I understand that I must request a QRD by contacting FSAFEDS directly at 1-877-372-3337. 13. RETIREMENT BENEFITS I understand that if I am placed on Absent-US, death and disability benefits continue under my retirement system. FERS employees and CSRS employees first hired on or after 01 Oct 1982: I understand that a military deposit is required to receive credit for this period of military service towards my civilian retirement, and the deposit must be paid in full prior to retirement. CSRS employees first hired on or before 1 Oct 1982: I understand that if I will be eligible for a Social Security benefit at age 62 or at retirement (which ever happens second), a military deposit is required to ensure continued credit in the computation of my retirement annuity. This deposit must be paid prior to retirement. If I will not be eligible for a Social Security benefit at age 62 or at retirement (which ever happens second), there is no need to pay a deposit. If I am restored under USERRA (return from military service within five years; exception during a period of National emergency), the deposit will be calculated using the lesser of the CSRS or FERS retirement contributions attributed to the period of military service, or the military deposit amount based on my military base pay. If I am not restored under USERRA, the military deposit calculation would be based on my military base pay if my military service was performed under 10 U.S.C. If my military service was performed under 32 U.S.C., I will receive credit for six months of each calendar year while on Absent-US. (Military service performed under 32 U.S.C. is not creditable unless the employee returns to civilian duty via exercise of restoration rights under USERRA, and pays the military deposit.) 14. EMPLOYEE AND SUPERVIS USERRA BRIEFING CERTIFICATION EMPLOYEE USERRA TRAINING CERTIFICATION I have reviewed the mandatory OPM USERRA training and understand my rights, responsibilities, and entitlements under USERRA. Date Signature SUPERVIS USERRA TRAINING CERTIFICATION I have reviewed the mandatory OPM USERRA training and understand my supervisory rights, responsibilities, and entitlements under USERRA and have properly counseled my employee accordingly. Date Supervisor s Title Supervisor s Signature Supervisor s Phone Number Supervisor s Email Address 4 of 5 July 2018 V1.5
15. RESERVIST DIFFERENTIAL Background: Under 5 U.S.C. 5538, employing agencies must pay differential payments to eligible Federal civilian employees who are members of the Reserve or National Guard 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" allowable to that pay period. Qualifying legal authorities include: 10 USC 331, 10 USC 332, 10 USC 333, 10 USC 688, 10 USC 12301(a), 10 USC 12302, 10 USC 12304, 10 USC 12304a, 10 USC 12305, 10 USC 12406 I have reviewed my military orders and my military orders do NOT fall within one of the nine authorities listed above. Skip to Section 6. I DO have military orders issued under a qualifying legal authority (above) and believe that I may be eligible for Reservist Differential payments. I must contact my servicing CPAC and provide my Leave and Earning Statements each month while deployed. I may also provide my LES' to my servicing CPAC within 30 days of my return to duty. 16. EMPLOYEE SIGNATURE My elections for this period of military active duty are marked above and I understand my elections. I understand that I must notify my supervisor and employing office when my tour is completed. I should review my LES and report any discrepancies I find within 2 pay periods of returning to duty. Should my orders change, it is my responsibility to provide new orders and a checklist to my agency. I have included the following forms with this checklist: Military Orders (Required) - My orders show my name, SSN, reporting date, purpose and legal authority: example 10 USC XXXX FEHB Premium Conversion Waiver Election (if applicable) Signature: Date: HUMAN RESOURCE OFFICE USE ONLY Initial off each item to verify completion: Military Orders or compatible notification attached and/or uploaded to DCPDS FEHB Premium Conversion Waiver (DG60) To be uploaded to eopf. CPAC USE ONLY Initial off each item to verify completion: Military Orders to AutoNOA eopf Upload Tool (DG 77) Checklist to AutoNOA eopf Upload Tool FEHB Premium Conversion Waiver (If Applicable) (DG 60) Reservist Differential to CHRA POC available on GPS Completed by (Name): Signature/Date Completed by (Name): Signature/Date 5 of 5 July 2018 V1.5