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LWOP / RTD

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 USERRA

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Checklist for Civilian Employees Entering Extended Active Duty

 

Employee instructions:  This checklist provides important information regarding your benefits.  Fill in the blanks or initial as appropriate for each item listed below.

 

Employee Full Name______________________________________________________

SSN__________________________        Date of Birth___________________________

Home Address____________________________________________________________

Telephone Contact Number_________________________________________________

Date of Entry on Active Duty Specified on Orders_______________________________

 

Note:  Employees are responsible for providing notice of their deployment to their agency as far in advance as reasonable.

________________________________________________________________________

 

I want to be:  (Initial one and provide effective date)

            _____Placed on LWOP-US, effective__________________

            _____Separated, effective___________________________

 

Leave:

            _____I have military leave that I want to use.  Number of Days:________

            _____I want to use part of my annual leave.  Number of Days:_________

            _____I want my annual leave to remain to my credit.         OR

            _____I want to be paid a lump sum for my annual leave balance.

 

Health Benefits:  (Initial to terminate or continue)

 

Note:  You must contact your Civilian Personnel or Human Resources office as soon as you return to your civilian position. It is the employee’s responsibility to ensure that FEHB coverage and premiums resume upon return to duty.

 

            _____My military service is for 30 days or less- my coverage will continue.  I need make no further election regarding health benefits, unless my military service is later extended past 30 Days.

 

            _____I want to terminate my FEHB coverage and I am aware that my coverage will terminate at the end of the pay period that my effective date of LWOP-US falls into.

 

                        OR

            _____I want to continue my FEHB coverage: (Initial one)

 

            _____I am being called to active duty in support of contingency operation.  My Agency will pay my share of the FEHB premium for up to 24months.  The 24 month period starts the date I am placed on LWOP-US.

 

 

             _____My active duty is not in support of contingency operation.  I am entitled to up to 24 months of continued FEHB coverage beginning the date my absence from my Civilian position begins, i.e., the effective date of my entrance on active duty.  I want to pay for my FEHB by: (initial one)

 

             _____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; the final 12 months must be paid on a current basis.

If you elect this option, you can pay the premium on a current basis by mailing a check or Money Order to:  Cleveland -- DFAS, PO Box 998019, Cleveland, OH  44199-8019 (Checks for payment of FEHB should include the technicians Social Security Number and FEHB in the Memo line of the check.

 

             _____Incurring a debt to be paid upon my return to civilian duty (on a pretax-basis if I participate in Premium Conversion) for the first 12 months.  After the first months, my share will be 102% of the cost and it must be paid on a current basis.

 

Premium Conversion:

            _____I understand that if I am participating in Premium Conversion, I have 60 days from the start of my unpaid leave of absence (LWOP-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.

 

Dental and Vision (FEDVIP)

 

           _____ I understand that in order to continue by Vision and/or Dental Coverage, to avoid termination of coverage, I must call FEDVIP to coordinate my payment options.

 

      _____ I also understand the LWOP-US is not a Qualifying Life Event in order to  terminate my Vision and/or Dental Coverage.

 

Transitional TRICARE:

            _____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.

 

Life Insurance:  (if enrolled)

            _____I understand that my FEGLI coverage will continue for 12 months in nonpay status (LWOP-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.  There is NO agency share.

            _____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 qualifying life event (QLE) while on LWOP-US, such as marriage, divorce, death of spouse, acquiring an eligible child, I must contact my employing agency no later then 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.

            _____I qualify to elect FEGLI coverage outside of an open season because I am a civilian employee being deployed in support of a contingency operation or I am designated as emergency essential personnel under section 1580 or Title 10 and I have completed the SF 2817 Life Insurance Election Form.  Elections apply to Basic, Option A Standard and Additional coverage only.

 

NOTE:            New FEGLI Election Opportunity is only civilians employees deployed in support of a contingency operation and employees designated as “emergency essential employees.”

 

Flexible Spending Accounts (FSAs): (if enrolled)

            _____I am aware that I must notify FSAFEDS of my entrance on LWOP-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 non pay status.  No contributions will be deposited into my account during my absence.

            _____I understand that I decide to separate from civilian service, my FSA will terminate as of the date of my separation.  There are no extension.  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 and Air National Guard.

 

            _____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 know as a qualified reservist distribution (QRD).

            _____I understand that return of the funds (QRD) is taxable income in the year that 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.  I understand I must request a QRD my contacting FSAFEDS directly at 1-877-372-3337.

 

Federal Employees Dental and Vision Insurance Program (FEDVIP):

            _____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 FENBEFEDS 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.

 

Federal Long Term Care (LTC) Insurance:

            _____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 option from payroll deduction, I must contact a LTC Representative on return to civilian duty if I want payment by payroll deduction reinstated.

Retirement:

            _____I understand that if I am placed on LWOP-US, death and disability benefits continue under my retirement system.

            _____CSRS Employees first hired on or after 10-01-1982: I understand that a military deposit is required to receive credit for this period of military service toward civilian retirement, and the deposit must be paid in full prior to retirement.

            _____CSRS employees first hired before 10-01-1982: I understand that if I will be eligible for a Social Security benefits at age 62, a military deposit is required to ensure continued credit in my computation of my retirement annuity.  This deposit must be paid prior to retirement.  If I will not be eligible for Social Security benefits at age 62, there is no need to pay 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 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 LWOP.  (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.)

 

Thrift Savings Plan:

            _____I understand that if I am restored to my civilian position under USERRA, I may make retroactive TSP contributions and elections, including missed catch up contributions, if otherwise eligible.  I understand that I will need to contact my employing office 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 may uniformed services TSP account while on active duty, I am responsible for providing ALL my military LES forms as documentation of those contributions.

            _____I currently have an outstanding TSP loan.  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 deduction from my military pay, and that 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 same, in order to avoid a taxable distribution.

 

Acknowledgement:  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.

 

Signature________________________________________  Date___________________

 

LWOP: Initial on the check list, only things that apply to you as an employee and please include a copy of your orders for contingency operations or for Military Schools. Include ANY paper work of you choose to change any of your benefits fpr example FEHB or TSP.

 

RTD: If you are RETURNING from contingency operations and would like your USERRA TSP and contributed to TSP while on Active Duty please include all military LES’. If you DID NOT contribute to TSP while on Active Duty, include a signed statement attributing to that fact.    

 

 

 

© NYS DMNA: Technician Resources - LWOP / RTD
URL: http://dmna.ny.gov/hro/tech/?page=1276788114
Page Last Modified: 18 Apr 14
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