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Fillable Printable OPM Form 1825

Fillable Printable OPM Form 1825

OPM Form 1825

OPM Form 1825

Form Approved
OMB 3206-0264
APPLICATION FOR U.S. FLAG RECOGNITION BENEFIT
FOR DECEASED FEDERAL CIVILIAN EMPLOYEES
General Information and Instructions:
Complete this form and submit it to the Federal Government agency that employed the deceased at the time of
his/her death. Contact the agency if you need help to complete this form.
Public Law 112-73 authorizes a Federal executive agency head to provide a United States flag under certain
circumstances (see page 2 for eligibility information).
INFORMATION ABOUT THE DECEASED FEDERAL CIVILIAN EMPLOYEE
Name of Deceased (Last, First, Middle Initial):
Last Four Digits of Social Security Number: Date of Death:
Cause of Death:
Death Certificate or Other Documentation Provided (if required by agency): Yes No N/A
Employing Agency:
INFORMATION ABOUT THE FLAG BENEFICIARY
Name of Beneficiary (Last, First, Middle Initial):
Address (number and street or rural route, city or P.O., and ZIP Code):
Relationship t o D e c e as e d:
ELIGIBILITY
Beneficiary: I CERTIFY that I am eligible to request this benefit
Print Name: (Last, First, Middle Initial)
Signature:
Date:
Authorized Agency Official: I CERTIFY that the EMPLOYEE is eligible for this benefit.
Print Name: (Last, First, Middle Initial)
Title of Authorized Agency Official:
Date Flag Issued:
Signature:
OPM 1825
February 2013
Form Approved
OMB 3206-XXXX
OPM 1825
February 2013
Eligibility:
Employees. An authorized agency official may, upon the request of a beneficiary, provide a United States flag on
behalf of an individual who
was an employee of the agency; and
died on or after December 20, 2011, of injuries incurred in connection with such individual’s employment
with the Federal Government suffered as a result of a criminal act, an act of terrorism, a natural disaster,
or other circumstance as determined by the President.
Beneficiaries. Anauthorized agencyofficialmay furnish a United States flag upon the request of a beneficiary ofa
deceased eligible employee in the following order of precedence:
widow or widower;
if none, to a child (including step, foster, or adopted child), according to age (i.e., oldest to youngest);
if none, to a parent (including step, foster, or adoptive parent);
if none, to a sibling (including step, half, or adopted sibling), according to age (i.e., oldest to youngest);
if none, to any individual related by blood or close family affiliation.
Privacy Act Notice:
The information you provide is for the purpose of determining your eligibility for a benefit under Public Law 112-
73, and the information will be protected from unauthorized disclosure. The collection, maintenance, and
disclosure of this information is governed by the Privacy Act. The information you provide on this form may be
disclosed without your consent by an agency maintaining the information in a system of records as permitted by
the Privacy Act, and by routine uses published by the agency in the Federal Register. The office that gave you
this form will provide you a copy of its routine uses. Completing this form is voluntary, though failure to complete
any part of the form other than the Social Security Number (SSN) may result in a delay or denial of benefits.
Executive Order 9397 (November 22, 1943) authorizes collection of the SSN to locate information in agency
records. Refusal to provide the SSN by itself will not result in a denial of benefits, though it may delay processing.
Information submitted is subject to verification through computer matching programs by written agreement with
other agencies.
Public Burden Information:
The OMB clearance number, 3206-0264, is currently valid. This information may not be collected, and you are
not required to respond, unless this number is displayed. Public reporting burden for this collection of information
is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to Reports and Forms Management Officer, U.S. Office of
Personnel Management, 1900 E Street, N.W., Room 5415, Washington, D.C. 20415. Do not send your
completed form to this address.
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