Fillable Printable Sf 1174

Sf 1174

CLAIM FOR UNPAID COMPENSATION OF DECEASED MEMBER OF THE UNIFORMED SERVICES

GeneralInformation:Anyassistancedeemednecessaryfortheproperexecutionofthisformwillbefurnishedtoallclaimantsby

the employingagency. Forwardthe completedformto theGovernmentagencyinwhichthe deceasedwas employedat time of

death.

Part A.

1. Name(s) and social security

number(s) of claimant(s)

2. Relationship to deceased

3. If minor, state age

4. Is designation of beneficiary for unpaid

compensation on file with service?

5. Are you named beneficiary?

6. Claimant(s) State of Legal Residence7. Name, rank or rating, service number, and

social security number of decedent

8. Date of Death

9. Name of Service

10. Decedent's domicile

(Yes or No)

PartB(Tobecompletedbythewidowofthedeceasedonly.)Doyoucertifythatyouweremarriedtothedecedent

and to he best of your knowledge and belief that the marriage was not dissolved prior to his/her death?

Part C

WIDOW OR WIDOWER AND DESIGNATED BENEFICIARIES DO NOT FILL IN PART C. ALL OTHERS MUST.

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

(a) Widow or widower.

(b) If no widow or widower survives, list each living child of the deceased (include natural, adopted, illegitimate, and

stepchildren

and indicate after names which class) or the descendants of deceased children.

(c) If not widow or widower, child or descendant of deceased children survives, list each surviving parent and state whether

nature, 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)

Name and Social Security NumberAge

Relationship to

Deceased

Address

(Continued on other side)

Standard Form 1174 (EG)

September 1992

4 GAO 26.1

(This Form has been authorized for local reproduction.)

SF 1174 (Back)

1. If noneofthe above survives and an executor or administrator has been appointed,the following statements should be

I/we have been duly appointed of the estate of the deceased, as evidence, as evidenced by

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

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 has been appointed, will one be

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

(Yes or No)

DESIGNATED BENEFICIARY, SURVIVING SPOUSE, CHILDREN, PARENTS, OR LEGAL REPRESENTATIVES DO NOT

FILL IN PART E. ALL OTHER MUST.

Part D

Part E

Have the funeral expenses been (If paid, receipted bill of the undertake must bee attached hereto.)

Whose money was used to pay the funeral

FINES, PENALTIES, and FORFEITERS are imposed by law for the making of false or fraudulent

claims against the United States or making of false statements in connection therewith.

(Signature of claimant)(Date)(Signature of claimant)(Date)

(Street address)(Street address)

(City, State and ZIP code)(City, State and ZIP code)

TWO WITNESSES ARE REQUIRED

We certify that we are well acquainted with the and that

thesignature(s) of the claimant(s) was(were) affixedinour presence.

(Name(s) of claimant)

(Signature of witness)(Signature of witness)

(Street address)(Street address)

(City, State and ZIP code)(City, State and ZIP code)

AllFederalchecksinpossessionoftheclaimant,drawntotheorderofthedecedent,inpaymentofpayandallowanceshouldaccompanythisclaim.

(Executor or administrator)

(Yes or No)