GSA5046
Civilian Employees Entering Extended Active Duty Checklist
GSA Form 5046, Civilian Employees Entering Extended Active Duty Checklist, is a General Services Administration (GSA) form, printed as GSA 5046 2/2020. GSA hosts it in its forms library; GSA's page lists no authority or regulation.
It is a five-page election and acknowledgement form for civilian employees entering active military duty, not a form the public files. The instructions say to fill in the blanks or select as appropriate, sign and date, and send all pages with the military orders to the Benefits and Retirement Center (BRC), [email protected], within 31 days of the date of entry on active duty.
It covers the status change (Absent-US or separation), military leave and Reservist Differential, health, life, dental, vision and long term care insurance, flexible spending accounts, retirement and the Thrift Savings Plan. A Benefits Specialist also signs. You can fill it out free in your browser on this page and download the result without an account.
Name, HR Links Employee ID Number, home address and phones, date of entry on active duty, whether the deployment supports contingency operations under 10 U.S.C. 101(a)(13), and placement on Absent-US or separation with effective dates.
Military leave days under 5 U.S.C. 6323(a) (up to 15 days), 6323(b) (up to 22 days) or unlimited leave for the D.C. National Guard under 6323(c), annual leave choices, and a Reservist Differential request.
FEHB choices by deployment length, how continued premiums are paid, the 60-day window to waive Premium Conversion, and a TAMP TRICARE acknowledgement.
FEGLI coverage in Absent-US or after separation, elections after a qualifying life event, and FSAFEDS notices, including Qualified Reservist Distributions.
Dental and vision enrollment and cancellation windows and direct billing, then long term care premium payments.
CSRS and FERS military deposit rules, retroactive TSP contributions and TSP loan suspension, then the employee and Benefits Specialist signatures.
The five pages run from the employee details to the acknowledgements.
Enter the name, HR Links Employee ID Number, home address, phone numbers and the date of entry on active duty specified in the orders, and answer the contingency operations question.
Select Absent-US or Separate with an effective date, then the military leave, annual leave and Reservist Differential choices that apply.
Select the statements that apply in the health, life, FSA, FEDVIP, FLTCIP, retirement and TSP sections, including a TSP loan number if there is one.
The employee signs and dates that the elections are marked and understood and that the supervisor will be notified when the tour is completed. A Benefits Specialist also signs.
Send all pages with the orders to the BRC at [email protected] within 31 days of the date of entry on active duty, give the immediate supervisor a copy and keep one.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
To the Benefits and Retirement Center (BRC), [email protected], within 31 days of the date of entry on active duty, with the military orders.
The form says to contact the BRC as soon as the employee returns, to notify the BRC immediately if a TSP loan was suspended, and to contact GSA's Payroll Services Branch at [email protected] within 60 days for retroactive TSP contributions.
FSAFEDS 1-877-372-3337. BENEFEDS 1-877-888-FEDS (3337), Teletypewriter (TTY) 1-877-889-5680. FLTCIP Representative 1-800-582-3337.
The form says military leave cannot be approved without actual documentation received prior to departing for military duty.
60 days to waive Premium Conversion, 60 days after a qualifying life event for FEGLI elections, 60 days after deployment to cancel FEDVIP, and 25 days to pay after a FEDVIP termination notice.
SF2809
100 fields, 18 pages
SF2810
29 fields, 7 pages
SF2817
37 fields, 5 pages
SF2823
64 fields, 3 pages
SF3102
34 fields, 3 pages
The form names the employee, a Benefits Specialist and the employee's supervisor.
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The form is printed by the General Services Administration as GSA 5046 2/2020. GSA hosts it in its forms library; GSA's page lists no authority or regulation.
The instructions say to send all pages with the military orders to the Benefits and Retirement Center (BRC), [email protected], within 31 days of the date of entry on active duty, give the immediate supervisor a copy and keep a copy.
Up to 15 days under 5 U.S.C. 6323(a), up to 22 days for emergency duty under 5 U.S.C. 6323(b), and unlimited military leave for members of the National Guard of the District of Columbia under 5 U.S.C. 6323(c).
For a deployment of 30 days or less, it says coverage continues. For longer deployments the employee chooses to terminate or continue. If the duty supports a contingency operation, the form says GSA will pay the employee's share of the premium for up to 24 months.
The form says FEGLI coverage continues for up to 24 months in non-pay status (Absent-US), with the first 12 months at no cost. Continuing for the additional 12 months means paying both the employee and agency shares of the premiums.
It says an employee restored under USERRA may make retroactive TSP contributions and elections by contacting GSA's Payroll Services Branch within 60 days of return, and that an outstanding TSP loan can be suspended while in non-pay status, with interest accruing.
The employee and a Benefits Specialist. The Benefits Specialist also adds a phone number and email address.
