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Supplemental Semiannual Headcount Report OPM 1523 - Official Federal Forms
| Supplemental Semiannual Headcount Report Form. This is a national form and can be used in OPM US Office Of Personnel Management . |
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Supplemental Semiannual Headcount Report 1. Address of Payroll Office (including department, bureau, location and zipcode) 2. Payroll office number 4. Date payroll paid 3. Report number 5. Pay Period From To 6. To Office of Personnel Management ATTN: Funds Control Branch P.O. Box 582 Washington, D.C. 20044-0582 7. Name of preparer (print) 8. Telephone number 9. I certify that items listed herein are correct. Signature of authorized official Date Number Enrolled Benefit Category Dollar Amount Deductions Made No Deductions Made A. Life Insurance 1. Basic 2. Standard - Option A 3. Additional - Option B a. To age 35 b. 35-39 c. 40-44 d. 45-49 e. 50-54 f. 55-59 g. 60 & up 4. Family - Option C 5. Post-Retirement - Basic 6. Total Life Insurance* B. Health Benefits 1. Regular 2. Payers of Full Premiums 3. Total Health Benefits* Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices This form may be locally reproduced Previous editions unusable American LegalNet, Inc. www.FormsWorkFlow.com OPM Form 1523 Revised October 2003 Supplemental Semiannual Headcount Report Payroll office number Report number Payroll paid date Page 2 Benefit Category Dollar Amount Aggregate Base Salary Number Enrolled C. Retirement 1. CSRS a. Regular Withholdings b. Regular Contributions c. Special Withholdings d. Special Contributions e. Regular Withholdings for Offset Employees f. Regular Contributions for Offset Employees g. Special Withholdings for Offset Employees h. Special Contributions for Offset Employees i. Salary Offset j. Military Deposits k. Civilian Service Credit CPDF Code 1,R 1,R 6,T 6,T C C E E Deductions Made No Deductions Made ** ** ** 2. FERS a. Regular Withholdings b. Regular Contributions c. Reserve Technicians Withholdings d. Reserve Technicians Contributions e. A/T Controllers Withholdings f. A/T Controllers Contributions g. Law Enforcement/Firefighters Withholdings h. Law Enforcement/Firefighters Contributions i. Salary Offset K K N N L L M M ** j. k. Military Deposits ** 3. Total Retirement* D. Grand Total (Dollars Only) E. Total Employees (and/or Annuitants) on Payroll * Dollar amount must agree with SF 2812 for same reporting period. ** Memo entry only (do not include on line 3, Total Retirement). American LegalNet, Inc. www.FormsWorkFlow.com Reverse of OPM 1523 Revised October 2003
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