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Fillable Printable SF 2800

Fillable Printable SF 2800

SF 2800

SF 2800

Application for Death Benefits
Civil Service Retirement System
Civil Service
Retirement System
This application is for use by persons applying for benefits which may be payable under the Civil Service Retirement System (CSRS)
because of the death of an employee, former employee, or retiree who was covered by CSRS at the time of his/her death or separation from
Federal service. You should have received an informational pamphlet entitled “Applying for Death Benefits Under the Civil Service
Retirement System” SF 2800-1, with this application. If you did not receive the pamphlet and the deceased was a Federal employee at the
time of his/her death, you should get a copy from the deceased’s employing agency. If the deceased was retired or a former employee not
yet receiving a retirement benefit, you should get a copy from the Office of Personnel Management (OPM). You can write to the Office of
Personnel Management at OPM, P.O. Box 45, Boyers, PA 16017-0045, call OPM’s Retirement Information Office at 1-888-767-6738, or send
us email at retire@opm.gov.
If the deceased was an employee at the time of death, send your completed application, with any attachments, to the personnel office in the
agency where the deceased was last employed. If the deceased was a former employee or annuitant at the time of death, send it to the
Office of Personnel Management, P.O. Box 45, Boyers, PA 16017-0045.
If your address changes before we give you a survivor annuity claim number, notify us in writing and give your name, date of birth, your
Social Security Number, and the deceased person’s name, date of birth and Social Security Number. If you have received your
claim number, notify us of the change by calling or writing as described above. Be sure to refer to your claim number.
Instructions For Completing Application
Section B - Information About the Applicant
Type or print clearly in ink. If you need more space in any
section, use a plain piece of paper with your name, date of birth,
and Social Security Number, and the deceased person’s name,
date of birth and Social Security Number, written at the top. If
you do not know an answer, write “unknown.” If you are
unsure of information (for example, if you do not know an
exact date), answer to the best of your ability, followed by a
question mark (?).
5. If you checked “designated beneficiary” and have a copy
of the form designating you as beneficiary, attach it to the
application. If you checked “parent,” both parents must
submit completed applications. If one is deceased, attach
a copy of the death certificate. Otherwise, provide name
and address of other parent in Section F, if known. If you
checked “executor or administrator of estate,” attach a
copy of the court order appointing you executor or
administrator. (Note that a court must have appointed
The following additional information should help you to
you; we will not pay you based on a will or other docu-
answer those questions on the application which are not
ment prepared by the deceased.)
entirely self-explanatory.
Section C - Information About the Deceased
Section A - Information About the Deceased
Person’s Spouse
6. 6.If deceased had ever applied for or received retirement
benefits, show the retirement claim number.
1. Attach a copy of your marriage certificate.
7. Recurring payments from the Office of Workers’
Compensation Programs, U.S. Department of Labor
(OWCP) and CSRS survivor annuity benefits usually are
If you were married by a priest, rabbi, pastor, Justice of
the Peace or other person empowered by the State to
perform marriages, check “Clergy/Justice of the Peace”.
not payable for the same period of time. If the deceased
If you were not married by someone empowered by the
had applied for or received benefits from the OWCP
State to perform marriages, check “Other” and explain
based on an illness or injury received resulting from a
condition of employment within the last two years,
indicate here. The OWCP claim number appears on the
(for example, “common law” or “tribal marriage”).
If marriage is common law and a State court has
determined that you were married, send a copy of the
U.S. Treasury checks and correspondence from OWCP.
court order or judgment. If you do not have a court order
8. See the pamphlet entitled “Applying for Death Benefits
or judgment, attach two notarized affidavits from persons
Under the Civil Service Retirement System” to help you
who are in a position to know the facts and clearly state:
(1) the relationship between you, your spouse, and the
determine which block to check.
person swearing to the affidavit; (2) the length of time
10. If the deceased had no former marriage, write “none.”
Attach copies of death certificates and complete copies of
court orders of divorce or annulment if these occurred on
or after May 7, 1985. If you are the spouse of the
deceased and you and the deceased were married more
than one time, be sure to show the date your prior
you and the deceased lived together; (3) the address or
addresses at which you resided while you lived together;
(4) whether there was any public announcement in con
-
nection with your common law marriage; (5) whether you
and the deceased were regarded among your neighbors,
friends, and relatives as being husband and wife during
marriage(s) ended.
Office of Personnel Management
CSRS/FERS Handbook for Personnel
Standard Form 2800
and Payroll OfficesThe June 2006 edition is usable.
Rev. December 2008
the time you lived together; and (6) how the person
swearing to the affidavit is in a position to know the facts
being presented in the affidavit.
In addition, your own affidavit is required. It should state:
(1) the date on which, and the State in which, you and
your spouse mutually agreed to become husband and
wife; (2) whether you or your spouse were ever married,
ceremonially or under common law, to anyone else before
entering into the common law relationship (if so, state in
your affidavit all the facts of each previous marriage,
including the date it took place and the date of the death
or divorce that ended it); and (3) any other facts you
believe will help prove you were husband and wife. You
may also submit other documents which show a husband
and wife relationship such as a naturalization certificate,
deeds, immigration records, insurance policies, passports,
child’s birth certificate, income tax returns, etc.
2.If you married the deceased more than once, give dates
that each marriage began and ended.
Section E - Information About the Deceased
Person’s Dependent Children
1. a.List, in order of birth date, all the surviving, unmarried,
dependent children of the deceased. List all such children
you know of, no matter where they live. A dependent
child is a son or daughter who is unmarried and:
was under age 18 at the time of the deceased person’s
death, including any:
1.adopted child, and/or
2.stepchild, and/or
3.recognized child born out-of-wedlock who lived
with the deceased in a regular parent-child rela-
tionship, and/or
4.recognized child born out-of-wedlock if there
was a judicial determination of support or if the
deceased made regular and substantial contribu-
tions for the support of the child.
is age 18 or older and unmarried, but who became
mentally and/or physically disabled before age 18 and
who, because of the disability, is incapable of self-
support.
is between ages 18 and 22, unmarried, and a full-time
student in a recognized educational institution.
b.Attach a copy of the birth certificate for each child for
whom you are applying.
d.Show how each child is related to the deceased. For
example, write “Child of marriage at death” for a child of
the deceased person’s marriage in force at the time of
death.
e.If the unmarried dependent son or daughter is 18 or over,
state whether he or she is a full-time student and/or
disabled. Adult children may submit separate applications
if they want separate payments made to them.
2.The mother of the unborn child, the legal guardian or the
person responsible for the child should send us the birth
certificate, when available.
3.d.If the person(s) in 3b. is(are) court appointed, indicate by
checking the “Legal Guardian” box. If you are the person
who is court appointed, attach a copy of the court
appointment to this application. If there is no court
appointment, check “Other” and write in the relationship
to the child, for example, mother, father, sister, etc.
Section F - Information About Other Heirs
Please give us information about other relatives who may be
able to inherit from the deceased. If you can’t give complete
information, do the best you can. List only people who were
living when the deceased died and who have the following
relationships to the deceased:
Widow(er) (unless named in Section C);
Children of the deceased not included in Section E
and the children of any deceased children (on a
separate sheet of paper, show the relationships of
descendants of deceased children to the deceased,
for example, John and Mary, children of deceased
son John, and Sue, child of deceased daughter Ann);
If there is no living widow(er) or child, list the
deceased person’s parents (if only one parent survives,
a copy of the deceased parent’s death certificate
should be attached, if available);
If there are no living relatives of the deceased as
described above and no court-appointed executor or
administrator as described in Section G, list other
relatives who can inherit from the deceased. The
people you list must be blood kin of the deceased.
Section G - Information About the Deceased
Person’s Estate
1.If someone was named as executor or administrator in the
deceased person’s will, but is not appointed by a court,
check “no.” If you have been appointed by a court, attach
a copy of the court appointment.
Section H - Active Military Service
You do not need to complete parts 1 and 2 of this section if the
deceased was retired at the time of death, since OPM already
has this information.
1.Indicate whether the deceased performed active duty that
terminated under honorable conditions in the Armed
Forces or other uniformed services of the United States.
Inactive service in reserve components of the uniformed
service is not creditable for retirement purposes. Service
in the National Guard is not usually considered active
Federal military service except when ordered to active
duty in the service of the United States and during an
initial (3 months or longer) training period. However,
Standard Form2800
Rev. December 2008
full-time National Guard duty is creditable, if the service
interrupts creditable civilian service and is followed by
reemployment (as explained in Chapter 43 of title 38) that
occurs on or after August 1, 1990.
If you have a copy of the deceased person’s DD 214s or
other discharge certificate(s) showing the dates of active
duty and the deceased was an employee at the time of
death, you should attach it (them) to your application.
2. Persons who performed active military service after
December 31, 1956, must pay or have paid a deposit to
receive credit for the military service.
If the deceased was an employee at the time of death, you
may pay or complete the payment of the deposit by com-
pleting the election form contained in SF 2800A, which
can be obtained from the agency where the deceased was
last employed. The agency can provide you with more
information about this deposit.
3. Indicate whether the deceased ever received or applied
for military retired pay.
If you are receiving military survivor benefits, the
deceased person’s military service is used for survivor
purposes, subject to a reduction equal to the amount of
your military survivor benefits. However, if such retired
pay was awarded on account of a service-connected
disability incurred in enemy combat or caused by an
instrumentality of war in the line of duty during a war
period, or was awarded under title 10, U.S. Code
Sections 12731 through 12739, (formerly Chapter 67,
title 10) (reserve retired pay at age 60 based on 20 years
of active and reserve service), no such reduction is
required. You should attach a copy of your award of
military survivor benefits to show that the award was
based on one of the above reasons.
Section J - Certification
1. Sign your name in ink. Please note that OPM will not
accept the signature of someone who has a power of attor-
ney for the applicant named in Section B. A court-
appointed fiduciary can apply on behalf of the applicant,
provided a court-certified copy of the court appointment is
attached to the application for death benefits. If there is
no court-appointed fiduciary and the applicant is not com-
petent, a relative or person responsible for the applicant
may sign. OPM will arrange later for the appointment of
a representative payee for the person named in Section B.
Section K - Applicant’s Checklist
Use this section of the application to ensure that all required
supporting documentation is attached.
SF 2800A
If the deceased was an employee at the time of death and
you are the surviving spouse or former spouse, you and the
deceased person’s agency should complete Standard Form
2800A, which can be obtained from the deceased person’s
employing agency. Instructions for completing SF 2800A
are contained on the form itself.
Privacy Act Statement
Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code). The information
you furnish will be used to identify records properly associated with your application for Federal benefits, to obtain additional
information if necessary, to determine and allow present or future benefits, and to maintain a uniquely identifiable claim file.
The information may be shared and is subject to verification, via paper, electronic media, or through the use of computer
matching programs, with national, state, local or other charitable or Social Security administrative agencies in order to
determine benefits under their programs, to obtain information necessary for determination or continuation of benefits 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 civil or criminal law. Executive Order 9397 (November
22, 1943) authorizes the use of the Social Security Number. Failure to furnish the requested information may delay or prevent
action on your application.
Public Burden Statement
We think this form takes an average of 45 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
this form, including suggestions for reducing completion time, to the United States Office of Personnel Management (OPM),
CRIS Publications Team, (3206-0156), Washington, D.C. 20415-3430. Completed application forms should not be sent to this
address. The OMB Number 3206-0156, is currently valid. OPM may not collect this information, and you are not required to
respond, unless this number is displayed.
Standard Form 2800
Rev
. December 2008
Civil Service
Retirement System
Form Approved
OMB No. 3206-0156
Application for Death Benefits
Civil Service Retirement System
Section A - Information About the Deceased
1. Full name of deceased (last, first, middle) 2. Date of birth (mm/dd/yyyy)
3. Date of death (mm/dd/yyyy) (Attach a certified copy of the death certificate) 4. Social Security Number
5. List any other names the deceased used (such as maiden name or his/her middle name) 6. CSA number (if retired)
7a. Was the deceased applying for or receiving workers' compensation from the Office of Workers' Compensation Programs
(OWCP), Department of Labor?
No Yes
7b. OWCP claim number
8. What was deceased person's employment status at time of death (see pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System")
Complete SF 2800A, which can be obtained from the deceased person's former employing agency. Former employee RetireeEmployee
9. Name of deceased person's spouse at time of death (if not married at time of death write "none")
10a. Name of deceased person's spouses from all former marriages 10b. How did each marriage end? 10c. Date each marriage ended
Death
Divorce/annulment
A court has awarded this
former spouse a survivor
benefit.
A court has awarded this
former spouse a survivor
benefit.
Death
Divorce/annulment
Section B - Information About the Applicant
1. Your full name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number
4a. Are you a citizen of the United States of America?
Yes No
4b. What country are you a citizen of?
5. I am applying for benefits as (check all boxes that apply):
Former spouse Complete Section D below
Executor or administrator of estate (attach copy of court order)
Child (or descendant of deceased child or guardian of minor or disabled child)
Designated beneficiary (attach copy of designation, if available)
Widow(er) Complete Section C below
Parent of decedent (Each parent should complete a separate application. If one
parent is deceased, attach a copy of the death certificate.)
Other (specify):
6. Did you cash any check(s) issued to the deceased after the date of death or did you withdraw from the deceased's savings or checking account retirement monies paid by
direct deposit after the date of death?
No
Any uncashed checks must be returned to the Treasury.
Yes
Section C - Information About the Deceased Person's Spouse
(Complete if you are the widow(er).)
1. Marriage performed by
Clergy/Justice of Peace
Other (explain)
2. Date of marriage (mm/dd/yyyy)
3a. Have you remarried after your spouse died?
No Yes
3b. Date of remarriage (mm/dd/yyyy)
4a. Have you ever applied for a survivor annuity based on the Federal service of a deceased spouse other than the one named above in Section A.1?
No YesGo to Section E Complete items 4b-4e below
4b. Name of deceased former spouse 4c. Date of birth (mm/dd/yyyy)
4d. Name of retirement system (for example, Civil Service, Foreign Service) 4e. Claim number (assigned to you by
retirement system in item 4d.)
Office of Personnel Management
CSRS/FERS Handbook for Personnel
Standard Form 2800
Rev. December 2008
and Payroll Offices
Page 1 of 4
(child of former
marriage, adopted, etc.)
3.
2.
(mm/dd/yyyy)
unmarried
1e. Age 18
or over
2.
Yes, attached No
No Yes
first
(mm/dd/yyyy)
(mm/dd/yyyy)
Disabled
6.
Yes
1c.
(mm/dd/yyyy)
1f. Child's Social
Security Number
Student
Other
Legal guardian
3b.
child
No Yes
No Yes
No
Yes When born, send birth certificate for child to OPM No
No Yes
Specify
Other
Legal guardian
Specify
Other
Legal guardian
Specify
3c. Name(s) of children
1d.
Child's relationship to deceased
3b. Give name and address of agency where you send health benefits premiums:
Are you paying for Federal Employees Health Benefits coverage to a former employing office?
Is there a child of the deceased not yet born?
5a.
Have you ever applied for a survivor annuity based on the Federal service of a deceased spouse or former spouse other than the one named on page 1, Section A.1?
4a. Have you married since your marriage to the deceased ended?
1a. Date of marriage to the deceased
1a. Are there any dependent children as defined in the instructions?
Is there a court order awarding you any portion of the deceased person's CSRS retirement or survivor benefits?
Section D - Information About the Deceased Person's Former Spouse
(Complete if you are a former spouse.)
Yes, on record at OPM
5b. Name of deceased former spouse
5d. Name of retirement system (for example, Civil Service, Foreign Service, etc.)
4b. Date of marriage after marriage to deceased ended
5e. Claim number assigned to you by retirement system in item 5d.
1b. Date of divorce or annulment from the deceased
5c. Date of birth
Section E - Information About the Deceased Person's Dependent Children
If you checked "Employee" in Section A.8, your former spouse performed more than 18 months of creditable civilian Federal service, you were married to the deceased
for at least 9 months, and a court awarded you all or a portion of the survivor annuity, contact the deceased person's employing agency in order to complete the
necessary election in Standard Form 2800A.
Date of birth1b. Name(s) of unmarried dependent children
(list in order of birth)
3a. Do you (the applicant) have responsibility for all the children in Section E.1?
Name and address of person having responsibility for child
3d. Custodian's Relationship to
Go to item 4a Go to item 3b
Go to item 5a Go to item 4b
Go to item 6 Complete items 5b-5e below
Complete items 1b-1f below
Go to Section F
Complete items 3b-3d below
Standard Form 2800
Page 2 of 4
Rev. December 2008
3.
1.
settle the estate of the deceased?
employing agency.
2.
1.
2.
1. 2. Complete address 3.
Yes
Yes
No
1.
From To
(Attach verification
4. Social Security
age 4.)
No
Yes No Don't know
Yes No Don't know
Yes No Don't know
Yes No
If an executor, administrator or other official has not been court appointed, will one be appointed?
All spouses and former spouses complete 3a-3c.
3a. Was the deceased receiving military retired pay at the time of death?
3b. Did the deceased ever waive military retired pay?
Has an executor, administrator or other official been appointed by the court to
Complete if deceased was an employee at time of death. Also, complete and attach Standard Form 2800A which can be obtained from the deceased person's
If any of the above listed service was performed after 12/31/56, was a deposit
made to the Retirement Fund for the service?
Public Law 104-134 requires that most Federal payments on or after July 26, 1996, be paid by direct deposit into a savings or checking account at a financial institution.
However, if receiving your payment electronically would cause you a hardship because it would cost you more than receiving your payment by check or you have a
disability or geographic, language or literacy barrier, you may receive your payment by check. Therefore, you must select one of the following:
Section H - Active Military Service
(Complete ONLY if you are the surviving spouse or former spouse)
Full name and address of person appointed
Section F - Information About Other Heirs
List other relatives who can inherit from the deceased as explained in the instructions. Do the best you can without delaying your application.
Full name of relative
Section G - Information About the Deceased Person's Estate
Relationship to deceased
Go to item 3 below
Complete if deceased was an employee at time of death. Do not complete if the deceased was retired at the time of death, since OPM already has this information.
If the deceased performed active, honorable service in the Armed Forces or other uniformed service as described in the instructions, complete all items below and attach a
copy of the discharge certificate or other certificate of active military service (if available).
1a. Branch of service
1b. Dates of active duty
3c. Are you eligible for military survivor benefits?
of your eligibility/ineligibility for such benefits.)
Number if known
Section I - Direct Deposit
Please send my annuity payments directly to my checking or savings account. (Go to item 2 on p
Please pay me by check. I have a hardship as described above. (Go to Section J.)
My permanent payment address is outside the United States in a country not accessible via direct deposit. (Go to Section J.)
Standard Form 2800
Page 3 of 4
Rev. December 2008
Remarks
5.
2.
?
Attached
(Continued)
3.
4.
verify this number.)
7.
8.
Checking
Savings
Special note:
6. Account number
Note:
1. (Sign in ink; do not print.)
2. Mailing address
3. 4. Date (mm/dd/yyyy)
Warning:
(18 USC 1001)
Required in all cases.
Document Title
Comments
Death certificate
Marriage certificate
or proof
Child(ren)'s birth
certificate(s)
are required.
you
Court papers
appointing
executor/administrator
Court papers
other fiduciary
military discharge
certificates
divorce/annulment
( )
Yes No N/A
Yes
No
Yes No
What kind of account is this?
Do you want to have your survivor annuity payments made to the same checking or savings account to which OPM made payments
by direct deposit to the deceased before his or her death (must be an active account and you must be a co-owner)
Section I - Direct Deposit
Do you want your survivor annuity payments made to a checking or savings account to which we have not already been making
payments by direct deposit?
Financial institution routing number (You may obtain this number by calling your bank, credit union, or savings institution.
This number is very important. We cannot pay by direct deposit without it. We suggest you call your financial institution to
Name and address of your financial institution
Telephone number of your financial institution (including area code)
If you prefer, you may attach a cancelled personal check that shows the information requested above, instead of filling in the requested financial institution
information. If you attach your personal check, it is especially important that you contact your bank, credit union, or savings institution to confirm that the information on the
check is the correct information for direct deposit.
(Some institutions, especially credit unions, use different routing numbers on checks.) OPM can use this information to start
paying you by direct deposit.
Section J - Certification
I hereby certify that all statements made in this application are true to the best of my knowledge and that no evidence relating to the settlement of this claim is withheld. I have
read and understand all of the information provided in the instructions to this application.
We cannot process your application if you do not complete all of Section J.
Signature of applicant named in Section B. Daytime telephone number
Any intentionally false or misleading statement or response you
provide in this application is a violation of the law punishable by a fine of not
more than $10,000 or imprisonment of not more than 5 years or both.
Best time to call you
Section K - Applicant's Checklist
Attach copies of the following documents to expedite the processing of your application.
Required if you were spouse of deceased at time of death (if married more than once,
provide copies of all certificates).
Affidavits or other proofs of common law marriage
Recommended for all children for whom are applying for benefits.
Required if you are applying as executor or administrator of deceased person's estate.
appointing guardian or
Required for minor or disabled children who have a court-appointed fiduciary.
Required for any incompetent applicant who has a fiduciary.
DD 214s or other Provide if you are applying as surviving spouse or former spouse and the deceased was
an employee at time of death. Failure to attach the information may delay the
processing of your claim.
Court order of Required from former spouse if not already on record at OPM.
Needed from other applicants if available.
Standard Form 2800
Page 4 of 4
Rev. December 2008
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