Request for Reimbursement Sample Letter
US Office of Personnel Management
OPM FERCCA IMPLEMENTATION TEAM
1900 E Street NW, Room 4H28
Washington DC 20415
Re: Request for Reimbursement of Out-of-Pocket Expenses
Dear Sirs:
My name is _______________________________, my SS# is
________________________,
and my address is
____________________________________________________________.
My phone number is (Day) ___________________ (Eve)
_________________________.
The name and address of my current or last Federal employer
is _____________________________________
Their phone number is___________________________________.
I was incorrectly placed in the ________________________________ retirement system on (date) _________________.
My retirement coverage was corrected to the ____________________________ retirement system on (date) _________________.
(OR)
My retirement coverage has not been corrected to the _____________________________ retirement system.
For Social Security taxes (FICA) and CSRS retirement deductions paid, please
provide the amount paid and the agency to which payment was made.
For reimbursement of interest paid on a CSRS (Offset) deposit, please
demonstrate why your election of CSRS (Offset) does not fully compensate you for
the error.
For all other expenses, please show (1) amount paid, (2) to whom paid, (3)
why you believe the expense resulted from the coverage error, and (4) how that
course of action would have corrected/mitigated the effect of the coverage
error.
Use appropriate closing:
I have attached copies of the necessary documents to prove my case (see
the OUT-OF-POCKET EXPENSE Instructions to determine what proof is
necessary).
(Or)
I have attached proof that I have paid these expenses (see the
OUT-OF-POCKET EXPENSE Instructions to determine what proof is necessary).
(Or)
I received a lump-sum settlement or court-ordered payment. A copy of the
agreement or order is attached.
(Or)
I received an award or other payment to cover some or all of my attorney
fees. A copy of the award or other document showing the details of the payment
is attached.
________________________________________
(Signature)
_________________________
(Date)