Standard Form 2812-A (SF 2812-A): Health Benefits Withholdings by Enrollment Code

Standard Form 2812-A (SF 2812-A), Report of Withholdings and Contributions for Health Benefits By Enrollment Code, is an Office of Personnel Management (OPM) form, Revised November 2013, with OMB 3206-0262. It lists the CSRS/FERS Handbook for Personnel and Payroll Offices, and GSA hosts a copy in its forms library.

The one-page report breaks health benefits withholdings and contributions down by enrollment code. For each enrollment code number it has a column for total withholdings and contributions and a column for the number enrolled. A footnote says the number of enrollees is required on the report for the last payroll periods paid during the 1st through the 15th of March and September.

The footer says the form may be locally reproduced, and OPM estimates an average of 30 minutes to complete it. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Standard Form 2812-A (SF 2812-A): Health Benefits Withholdings by Enrollment Code, as printed by GSA

What's on SF 2812-A

Department and office

Department or establishment, bureau, division or office, and address including ZIP Code.

Payroll details

Payroll Office number, report number, pay period from, pay period to, date payroll paid and agency telephone number.

Enrollment code columns

Three sets of columns side by side, each with Enrollment Code No., Total Withholdings & Contributions and Number enrolled.

Number enrolled footnote

The footnote says the number of enrollees is required on the report for the last payroll periods paid during the 1st through the 15th of March and September.

Public burden statement

OPM's estimate of 30 minutes to complete the form and the statement that OMB Number 3206-0262 is currently valid.

How SF 2812-A is completed

1
Fill in the header
Enter the department, bureau and address, the payroll office number, report number, pay period dates, date payroll paid and agency telephone number.
2
List each enrollment code
Enter each enrollment code number in an Enrollment Code No. box. The page has three column sets, each with the same three columns.
3
Enter the totals
Next to each code, enter the total withholdings and contributions for that code.
4
Add the number enrolled when required
The footnote says the number enrolled is required for the last payroll periods paid during the 1st through the 15th of March and September.

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Where it goes and what the form says

Where it goes

The PDF prints no filing address for the report. Its burden statement sends comments on the time estimate to the Office of Personnel Management, Funds Management, P.O. Box 582, Washington, DC 20044.

Time to complete

OPM estimates an average of 30 minutes, including the time for reviewing instructions, getting the needed data and reviewing the completed form.

Copies and OMB number

The footer says the form may be locally reproduced. The burden statement says OMB Number 3206-0262 is currently valid and that OPM may not collect the information unless the number is displayed.

Who completes SF 2812-A?

The department or establishment
The header names the department or establishment, the bureau, division or office, its address including ZIP Code, and the agency telephone number.
The payroll office
The payroll office number, report number, pay period from and to, and the date payroll paid identify which payroll the totals cover.
Not individual enrollees
Rows hold a total per enrollment code and a count of people enrolled. No item asks for an enrollee's name or Social Security number.
No signature or mailing address
The PDF prints no signature line and no address for sending the report. The only address is in the burden statement, for comments on the time estimate.

It is an agency payroll report, not a form for individual enrollees. The form prints these blocks.

Official sources and the blank

Official GSA form page
The agency’s own page for Form SF2812A.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form SF2812A

Who issues SF 2812-A?

The form is printed as an Office of Personnel Management form, Revised November 2013, OMB 3206-0262, and lists the CSRS/FERS Handbook for Personnel and Payroll Offices. GSA hosts a copy in its forms library.

How is SF 2812-A different from SF 2812?

SF 2812 reports withholdings and contributions by benefit category for life insurance, health benefits and retirement. SF 2812-A covers health benefits only, listed by enrollment code with the number enrolled. Both print OMB 3206-0262.

When is the number enrolled required?

The footnote says the number of enrollees is required on the report for the last payroll periods paid during the 1st through the 15th of March and September.

Do enrollees fill out SF 2812-A?

The form is an agency payroll report. Its rows hold totals and counts per enrollment code, and no item asks for an enrollee's name or Social Security number.

How long does SF 2812-A take?

OPM estimates an average of 30 minutes to complete it, including reviewing instructions, getting the needed data and reviewing the completed form.

Standard Form 2812-A (SF 2812-A): Health Benefits Withholdings by Enrollment Code