DS-5112 Fillable PDF – Federal Employees Health Benefits Enrollment Form

The DS-5112 is the official Department of State form used to document enrollment in the Federal Employees Health Benefits (FEHB) program under Part 89 of Title 5 of the United States Code. Federal employees and retirees must provide accurate personal information, including Social Security Number, to ensure proper benefits coverage.

What Is the DS-5112 Form?

This form collects:

• Full name, address, and contact details
• Social Security Number (SSN)
• Employment status and agency information
• Beneficiary details for dependent coverage
• Signature and date of enrollment

How to Complete the DS-5112 Online with Formize

Instead of downloading, printing, and scanning, you can fill the form directly in your browser. Follow these simple steps:

• Click the "Fill out this form" button on this page.
• Wait a few seconds while the Formize PDF Filler app loads.
• Enter your information in each fillable field. The interface saves your progress automatically.
• Review the completed form, then click Submit to download a signed PDF copy.

Common Mistakes to Avoid When Filling DS-5112

• Incorrect SSN: Double‑check the nine‑digit number; a typo can delay benefits.
• Missing signatures: The form is invalid without a hand‑written or electronic signature.
• Out‑of‑date address: Use your current mailing address to receive official notifications.
• Leaving optional fields blank: If a field asks for "N/A," enter it exactly as shown.

Where to Submit the Completed Form

After you download the signed PDF, email it to your agency’s HR benefits office or upload it through the agency’s secure portal. Keep a copy for your records.

Need help? Review the official DS-5112 PDF for reference, or contact your HR representative.