Fillable Printable SF 1153

SF 1153

CLAIM FOR COMPENSATION OF DECEASED CIVILIAN EMPLOYEE

Standard Form 1153

Revised August 2011

All other previous editions are not usable

Form Approved

OMB No. 3206-0234

If you need more room, write "See Attached" in Part B. On a blank sheet

(the attachment), print your name, date of birth and social security

number at the top. List the information required in Part B for each

beneficiary. Sign the form and attachment having the same two people

witness both of your signatures..

GENERAL INFORMATION

• Complete this form and send it to the Federal Government agency that employed the deceased at the time of

his/her death. Contact that agency if you need help to complete this form.

• All Government checks in your possession, drawn to the order of the deceased in payment of “unpaid compensation,”

should accompany this claim. All Government checks drawn to the order of the deceased for other purposes (such as

veterans’ benefits, social security benefits, or Federal tax refunds) should be returned to the agency that sent it.

PART A

1. Name of deceased 2. Social Security Number of deceased

3. Last address of deceased (if known)

4. Date of death

5. Employing agency

INSTRUCTIONS

• If you are a designated beneficiary of the deceased, complete Parts B and G.

• If you are the widow or widower of the deceased, complete Parts B, C, and G.

• If you are

not

a designated beneficiary of the deceased but you are a relative or next of kin of the deceased, complete

Parts D and G.

• If you are an executor or administrator of the deceased’s estate, complete Parts E and G.

• If you do not meet the criteria in Items 1 through 4, complete Parts F and G.

PART B

1. Is a Designation of Beneficiary for Unpaid Compensation (SF 1152) on file with the agency?

Yes

Don’t know

Full Name/Legal entity,

e.g., Trust

Social Security

Number Age

Relationship

to deceased Address

PART C

Do you certify that (1) you were married to the deceased

and

(2) to the best of your knowledge and belief the marriage

was not dissolved prior to his/her death?

Yes No

PART D

1. List below the name, social security number, age, relationship, and address of:

(a) If no widow or widower survives, list each living child of the deceased and state whether natural, adopted,

illegitimate or stepchild.

(b) If no child survives, list each living descendant of the deceased children.

whether natural, step, foster, or adoptive parent.

(d) If none of the above survives, list the next of kin who may be capable of inheriting from the deceased (brothers,

sisters, descendants of deceased brothers and sisters).

Full name

Social Security

Number Age

Relationship

to deceased Address

U.S. Office of Personnel Management

CFR 178, Subpart B

(continue on other side)

NSN 7540-00-634-4341

1153

PART E

1. If none of the individuals listed in Parts B and D survives and an executor or administrator of the deceased’s estate has

been appointed, the following statement should be completed.

I/we have been duly appointed

(Executor or Administrator)

of the estate of the deceased, as

evidenced by certificate of appointment herewith, administration having been taken out in the interest of

(Name, address, and relationship of interested relative or creditor)

and such appointment is still in full force and effect.

NOTE:

If making claim as the executor or administrator of the estate of the deceased, no witnesses are required, but a

court certificate evidencing your appointment must be submitted.

2. If no administrator or executor of the deceased’s estate has been appointed, will one be appointed? Yes No

PART F

1. Have funeral expenses of the deceased been paid? Yes No Don’t know

(If paid, receipted bill of the funeral director must be attached.)

Whose money was used to pay the funeral expenses? .

PART G

Fines

Penalties

and

Forfeitures

are imposed by law for making false or fraudulent claims against the United States or

making false statements in connection therewith.

Signature of claimant Date

Street address

City, State, and Zip Code

Signature of claimant Date

Street address

City, State, and Zip Code

Two Witnesses are Required

Signature of witness Date

Street address

City, State, and Zip Code

Signature of witness Date

Street address

City, State, and Zip Code

Privacy Act and Public Burden Statement

Solicitation of this information is authorized by the Code of Federal Regulations, Part 178, Subpart B. The information you

furnish will be used to determine the amount, validity, and the person(s) entitled to the unpaid compensation of a deceased

Federal employee. The information may be shared and is subject to verification, via paper, electronic media, or through the use

of computer matching programs to obtain information necessary for determination of entitlement under this program or to report

income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are

investigating a violation or potential violation of the civil or criminal law. Public Law 104-134 (April 26, 1996) requires that any

person doing business with the Federal government furnish a Social Security Number or tax identification number. This is an

amendment to title 31, Section 7701. Failure to furnish the requested information may delay or make it impossible for us to

determine your eligibility to receive payments.

We think this form takes an average of 15 minutes per response to complete, including the time for reviewing instructions, getting

the needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of SF 1153,

including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Reports and Forms Officer,

Paperwork Reduction (3206-0234), Washington, D.C. 20415-7900. The OMB number 3206-0234 is currently valid. OPM may

not collect this information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management Standard Form 1153

CFR 178, Subpart B Revised

Aug

2011

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