I, ______________________________________ (print name) hereby elect the following option under Part 1 of the settlement formula in the class action case of Frances Johnson-Feldmann, et al. v. Anthony J. Principi, Secretary, Department of Veterans Affairs, EEOC case
No. 100-A0-7234x.

_________I elect to take Option A, the one time, lump sum payment reflecting my lost back pay.

_________I elect to take Option B, the recalculation of my annuity based on a revised “High-3" salary submitted to OPM.

In making this election, I certify that I have received the Notice of Settlement and Settlement Agreement in the above captioned case and that I understand my election. I understand that once this election is made and the deadline has passed for making the election (within 15 days of the Administrative Judge’s decision approving the settlement), it cannot be changed.

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Signature

Date ________________

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Social Security Number (required)

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CSA or OPM Retirement Number (required)