Checklist/Acknowledgement of Benefits

NAME:______

Return To Duty (RTD) Checklist

Checklist/Acknowledgement of Benefits forTechnicians Returning from Military Active Duty

You are requiredto complete thischecklistregarding your benefits options and return it to your supervisor who will attach it to your electronic SF 52 in DCPDS for Return to Duty (RTD). Contact your Human Resources benefits specialist with any questions.

Leave

Military Leave: / Technicians who perform active military duty may request the use of paid military leave while on AUS with their Time-Keeper.
Annual Leave: / Technicians who enter active duty may request, through their Time-Keeper, to use all, a portion, or none of their annual leave while on AUS.
Return to Duty (RTD): Day after Order ends / First Day of Work:
Military Orders Ended:
Administrative (Presidential-5 days) Leave: / To
Military Leave: / To
Annual Leave: / To
Leave Without Pay (LWOP): / To
Signature / Date

USERRA Rights

I understand that I have USERRA rights as a federal technician as listed below:
Depending on the number of days I was on active duty I will have to return to duty as a federal technician if:

181 days or more on orders = within 90 days
31-180 days = within 14 days
Less than 31 days = 1st regular scheduled work day

USERRA is a federal law intended to ensure that persons who serve or have served in the Armed Forces, Reserves, National Guard or other “uniformed services”:

Are not disadvantaged in their civilian careers because of their service;
Are promptly reemployed in their civilian jobs upon their return to duty; and
Are not discriminated against in employment based on past, present, or future military service. The federal government is to be a “model employer” under USERRA (38 U.S.C. § 4301)

Employees with more than 90 days of uniformed service – Agencies must restore the employee:

To the position they would have attained had the employment not been interrupted by military service (Escalator Principle), (or a position of like seniority, status and pay), or
To the position in which they were employed on the date of the commencement of service (or a position of like seniority, status and pay), but only if they are unable to perform the duties of the new ‘escalator’ position after reasonable efforts.

Administrative Leave

I understand I may be entitled to 5 consecutive days of administrative leave (paid time off) upon return if:
My active duty was in support of contingency operationsuch as Operation Noble Eagle, Enduring Freedom, Iraqi Freedom, or any other subsequently established operation (Executive Order 13223).The days must be used consecutively once order ends and returned to duty, but prior to resuming work duties.

Leave and Earnings Statement (LES)

I am responsible formonitoring my LES for correct compensation and deductions upon returning to duty.

Federal Employee Health Benefits (FEHB)

Please initial ONLYONE option.

I DID NOT have FEHBcoverage prior to AUS:
I did not have coverage prior to active duty service, but may enroll through the EBIS website under the Qualifying Life Event (QLE):Due to loss of TRICARE coverage.
I elected to continue FEHB coverage while serving under Contingency (Title 10)at no cost:
Once I return to duty, I will resume paying my share of the premiums.
I elected to continue FEHB coverage while serving under Title 32 Military Service:
Once I return to duty, I am responsible for paying my portion of any unpaid premiums for that time period. Premiums are automatically deducted from my LES each pay period until completed, unless a different option is offered / approved by DFAS. I will see two FEHB premiums deducted from my LES; one for my regular FEHB premium and one to repay the owed premium.
I have transitional TRICARE (TAMP) benefitsand will reinstate FEHB coverage myself:
On the AUS Checklist I electedto suspend coverage myself through EBIS. It is my responsibility to reinstate my FEHB through EBIS. I may contact the Army Benefits Center (ABC-C) with any questions onreinstating my FEHB coverage. (Effective date will be the next pay period after my transaction was input into EBIS.)
*(Complete transaction in pay period prior topay period TRICARE expires without break in coverage)*
EBIS through ABC-C: (877) 276-9287
I elect HRO to reinstate my FEHB coverage upon Returning To Duty
On the AUS Checklist I elected HRO to suspend my FEHB coverage upon entering military service. I understand that HRO will reinstate my previous FEHB coverage with the effective date of my RTD.

Federal Employee’s Dental and/or Vision (FEDVIP)

I AM NOTcurrently enrolled in FEDVIP, but understand that:
I can use my return to duty as a Qualifying Life Event (QLE) to enroll. I have 60 days after returning to duty to be eligible outside of open season.
I AM currently enrolled in FEDVIP and:
Understand that I was responsible to pay the premiums for FEDVIP benefits in non-pay AUS andit will continue to be my responsibility to pay the premiums upon returning to duty.
Contact FEDVIP at 1-877-888-3337 with additional questions.

Federal Employee Group Life Insurance (FEGLI)

I DO NOT have FEGLI coverage.
I DOhave FEGLI coverage and payments will resume upon returning to duty.

Flexible Spending Accounts (FSA)

I DO NOT have a Flexible Spending Account
I DO have a FSA and am responsible to contact FSA Feds to inform them of my Return to Duty.
Elections I made when entering active duty will determine options available to me for my FSA account.
(i.e. allotment adjustments, qualifying life event to reenroll)
You can contact FSA Feds at 1-877-372-3337 if you have additional questions.

Thrift Savings Plan (TSP)

I understand no contributions could have been made to my civilian TSP while in non-pay AUS, however:
I may make retroactive contributions and elections to my TSP account within 60 days of my return to duty, and that my agency will make up missed agency contributions for eligible FERS employees. I need to contact HRO to indicate my desire 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 and that I am responsible for providing documentation of any TSP contributions while on active duty.
Please initial only one
I DO NOT have a TSP Loan
I DOhave a TSP loan:
Payments were suspended while in a non-pay status during my active military service. Loan payments will resume upon notifying HR of my return to duty and a TSP-41 submitted. If I fail to do this within 90 days after release from active duty, the loan may have to be recalculated or a taxable distribution may be declared. I am also responsible for reviewing my Leave and Earnings Statement to ensure correct loan payments are submitted on time.
You can contact TSP at 1-877-968-3778 if you have additional questions.

DD 214

I am responsible for:
Notifying HRO of my military service end date upon release from active duty and provide my DD 214.

Retirement / Military Deposit

I understand that this period of military (AUS) service is potentially creditable and I may request:
To make a military deposit for the service when in a non-pay status,complete a RI20-97 and attach the DD 214 with all inclusive LESs. All documentsare mailed or faxed to the appropriate DFAS (on page 2 of RI20-97). If paid within three years from RTD, no interest is charged.

National Guard Association of the United States (NGAUS) Disability Insurance:(30 days to make an election)

Please initial ONLYone option.

I DO NOT have NGAUS Disability Insurance.
I elect TO reinstate my NGAUS Disability Insurance that was suspended after 30 days of being on AUS.
I elect NOT to reinstate my NGAUS Disability Insurance that was suspended after 30 days of being on AUS.

National Guard Association of the United States (NGAUS) Life Insurance:

I DO NOT have NGAUS Life Insurance.
I DO have NGAUS Life Insurance and understand:
Premiums were direct billed and I was responsible for payment on non-pay AUS. Premiums will continue to be direct billed until my return to duty is reconciled with payroll, thenreturn to automatic deduction.
Contact NGAUS at 1-800-955-7736 if additional questions.

Long Term CareInsurance (LTCI)

I DO NOT have Long Term Care Insurance (LTCI)
I DO have LTCI and was responsible for paying my premiums while on AUS and:
It will continue to be my responsibility to pay the premiums upon returning to duty.
FLTCIP (800) 843-3557

\\ng\ngwi\Public\JFHQ\DHR-J1\Human Resources\HR-Services\USERRA, AUS & RTD\2.RTD_Checklist(Jan14).docPage 1 of 3