Login

Fillable Printable SF 3104

Fillable Printable SF 3104

SF 3104

SF 3104

Form approved:
Application for Death Benefits
OMB number 3206-0172
Federal Employees Retirement System
Federal Employees
Retirement System
This application is for use by persons applying for benefits which may be payable under the Federal Employees Retirement System
(FERS) because of the death of an employee, former employee, or retiree who was covered by FERS 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
Federal Employees Retirement System, SF 3114 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
either write to the Office of Personnel Management at OPM, FERS, P.O. Box 45, Boyers, PA 16017-0045 or call OPM's Retirement
Information Office at 1-888-767-6738. You can also access SF 3114 at www.opm.gov/retirement-services/publications-forms/.
If the deceased was an employee at the time of death, send your completed application, with any requested 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 OPM, FERS, P.O. Box 45, Boyers, PA 16017-0045.
If your address changes before you receive your claim number, write to OPM, giving 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, please refer
to it.
Instructions For Completing Application
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
(?).
The following additional information should help you to answer
those questions on the application which are not entirely
self-explanatory.
Section A - Information About the Deceased
6.If deceased had ever applied for or received retire-
ment benefits, show the CSA number (retirement claim
number).
7.Recurring payments from the Office of Workers'
Compensation Programs (OWCP), U.S. Department of
Labor and FERS survivor annuity benefits and/or
the FERS Basic Employee Death Benefit usually are
not payable for the same period of time. If the
deceased ever applied for or received benefits from
OWCP based on an illness or injury resulting
from a condition of employment, indicate here.
The OWCP claim number appears on correspondence
from OWCP.
8.See the pamphlet entitled, Applying for Death
Benefits Under the Federal Employees Retirement
System, SF 3114 to help you determine which block
to check.
10.If the deceased had no former marriage(s), write
"none." Attach copies of death certificates, divorce
decrees from former marriage(s) or annulment(s). If you
are the spouse of the deceased and were married to the
deceased before, be sure to show the date your prior
marriage(s) ended.
Section B - Information About the Applicant
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 certifi-
cate. Otherwise, provide name and address of other
parent in Section F, if known. If you checked "Execu-
tor or administrator of estate," attach a copy of the
court order appointing you executor or administrator.
(Note that a court must have appointed you; we will
not pay you based on a will or other document
prepared by the deceased.)
Section C - Information About the Deceased Person's
Spouse
1.Attach a copy of your marriage certificate.
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". If you were not married by someone
empowered by the State to perform marriages, check
"Other" and explain (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 court order or judgment. If you do not have a
court order or judgment, attach two notarized affida-
vits from persons who are in a position to know the
facts which clearly show: (1) the relationship
Instructions
Standard Form 3104
Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices
- 1 -
Revised May 2013
Previous editions are not usable.
between you, your spouse, and the person swearing
to the affidavit; (2) the length of time 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 connection 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 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
show: (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 which
ended it); and (3) any other facts which 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 certif-
icate, deeds, immigration records, insurance poli-
cies, passports, child's birth certificate, 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
1a. List, in order of birth date, all the surviving, unmar-
ried, 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 per-
son'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 relationship, 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
contributions for the support of the child.
is age 18 or older, but who became mentally
and/or physically disabled before age 18 and who,
because of the disability, is incapable of self-
support. Attach a copy of the Social Security
Administration's determination of disability (prior
to age 18) for disabled child(ren) over age 18.
is between ages 18 and 22 and who is unmarried
and a full-time student in school.
1b.Attach a copy of the birth certificate for each child
for whom you are applying.
1d.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.
1e.If the unmarried dependent son or daughter is 18 or
over, state whether he or she is a full-time student
and/or disabled.
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.
3d. 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.
4.You must apply for benefits from the Social Security
Administration (SSA) for minor or disabled children
of the deceased. Federal Employees Retirement
System (FERS) benefits to children will not be paid
until we have received verification of their entitlement
to (and amount of) or lack of entitlement to SSA
benefits. You should submit a copy of SSA's notice of
award or denial with this application, if available. If it is
not submitted, we will obtain the information from SSA,
however, this may delay the processing of your claim.
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.
Instructions
-2 -
Standard Form 3104
Revised
May 2013
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 hasn't been
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 the Office of
Personnel Management (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 services is not creditable for retire-
ment 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. However, full-time National
Guard duty (as defined in Section 101(d) of Title 10) 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 the
deceased was a retiree, OPM already has information about
his/her military service.
If you have a copy of the deceased person's DD 214's
or other discharge certificate(s) showing the dates of
active duty and the deceased was a former 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 under the Federal Employees Retire-
ment System (FERS) 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
completing the election form contained in Documenta-
tion and Elections in Support of Application for Death
Benefits when Deceased was an Employee at the Time of
Death, Standard Form (SF) 3104B, which can be obtained
from the agency where the deceased was last employed.
The deceased's agency can provide you with more infor-
mation regarding 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 Chapter 1223, title 10,
U.S. Code (formerly Chapter 67, Title 10), no such
reduction is required. You should attach a copy of your
award of military survivor benefits verifying the award
was based on one of the above reasons.
Section I - Payment Instructions
Complete in all cases. The US Department of the Treasury pays
all Federal benefit payments electronically. Most Federal
payments are paid by Direct Deposit into a savings or checking
account at a financial institution. If you do not have a bank
account, or prefer not to have your survivor annuity payments
deposited directly to your bank account, you can choose a
Direct Express debit card. If you choose this option, your
annuity payment will be automatically deposited to the Direct
Express card on the payment date. To obtain a debit card, go to
www.godirect.org or call 1-800-333-1795. If your payments are
not electronically deposited to your account and you do not
have a Direct Express card, you must contact the Department of
Treasury at 1-800-333-1795.
You cannot receive your survivor annuity payments by direct
deposit or the Direct Express debit card program if your
permanent payment address is outside the United States in a
country where these programs are not available.
Section K - Applicant's Checklist
Use this section of the application to ensure that all required
supporting documentation is attached.
SF 3104A
If the deceased was a retiree at the time of death and you are the
surviving spouse, you should complete Survivor Supplement
(FERS), SF 3104A, which is attached to this application.
Instructions for completing SF 3104A are contained on the form
itself.
SF 3104B
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 Documentation and Elections
in Support of Application for Death Benefits when Deceased
was an Employee at the Time of Death, SF 3104B, which can be
obtained from the deceased person's former employing agency.
Instructions for completing SF 3104B are contained on the form
itself.
Privacy Act Statement
Solicitation of this information is authorized by the Federal Employees Retirement law (Chapter 84, 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. 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 prevent action on your application.
Public Burden Statement
We estimate this form takes an average of 60 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), Retirement Services Publications Team (3206-0172), Washington, D.C. 20415-3430. Completed application forms should not be sent to
this address. The OMB Number 3206-0172, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Instructions
-3 -
Standard Form 3104
Revised May 2013
Form Approved
Application for Death Benefits
OMB No. 3206-0172
Federal Employees Retirement System
Federal Employees
Retirement System
Section A - Information About the Deceased
1. Full name of the 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 (ex. 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 the employment status of the deceased at the time of death (see pamphlet entitled, Applying for Death Benefits Under the Federal Employees Retirement
System, SF 3114)
Complete SF 3104B, which can be obtained from the
Former Retiree If you are the surviving spouse,
Employee
former employing agency of the deceased.
employee complete SF 3104A (attached)
9.Name of the spouse of the deceased at the time of death (if not married at time of death write "none")
10a. Name of the spouses from all former marriages of the
deceased
10b. How did each marriage end? 10c. Date each marriage ended
(mm/dd/yyyy)
Death Divorce/annulment
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
4.Are you a citizen of the United States of America?
Yes
No
5. I am applying for benefits as (check all boxes that apply):
Widow(er) complete Section C below
Executor or administrator of estate (attach copy of court
order)
Designated beneficiary (attach copy of designation, if available)
Former spouse Complete Section D on page 2
Parent of decedent (Each parent should complete a separate
application. If one parent is deceased, attach a copy of the death certificate.)
Other (specify):
Child (or as guardian of minor or disabled child)
6. Did you cash any check(s) issued to the deceased or did you withdraw funds paid by direct
deposit from the deceased's savings or checking account after the date of death?
Yes
No
Section C - Information About the Spouse of the Deceased (Complete if you are the widow[er].)
1. Marriage performed by
Clergy/Justice of the Peace Other (explain)
2. Date of marriage (mm/dd/yyyy)
3.Have you remarried after your spouse died?
Yes No
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 Go to Section E
4b. Name of deceased former spouse
Yes Complete items 4b-4e below
4d. Name of retirement system (e.g. Civil Service, Foreign Service)
4c. Date of birth (mm/dd/yyyy)
4e. Claim number (assigned to you by
retirement system in item 4d.)
If you will be receiving monthly payments, make sure you complete the payment instructions in Section I.
Office of Personnel Management
Page 1 of 4 Standard Form 3104
CSRS/FERS Handbook for Personnel and Payroll Offices
Revised May 2013
Section D - Information About the Former Spouse of the Deceased (Complete if you are a former spouse)
1a. Date of marriage to the deceased (mm/dd/yyyy) 1b. Date of divorce from the deceased (mm/dd/yyyy)
2. Is there a court order awarding you any portion of the Federal Employees Retirement System (FERS) retirement or survivor benefits of the deceased?
Yes, on record at OPM Yes, attached No
3a. Are you paying for Federal Employees Health Benefits coverage to a former employing office?
No Go to item 4a Yes Go to item 3b
3b. Give name and address of agency where you send health benefit premiums:
4a. Have you married again since your marriage to the deceased? 4b. Date of first marriage after marriage to the deceased ended (mm/dd/yyyy)
No Go to item 5a Yes Go to item 4b
5a. Have you ever applied for a survivor annuity based on the Federal service of a
Complete items
deceased spouse or former spouse other than the one named on page 1, Section A1?
No Go to Section E
Yes
5b-5e below
5b. Name of deceased former spouse (last, first, middle initial) 5c. Date of birth (mm/dd/yyyy)
5d. Name of retirement system (ex. Civil Service, Foreign Service, etc.) 5e. Claim number assigned to you by retirement system in item 5d.
If you will be receiving monthly payments, make sure you complete the payment instructions in Section I.
Special Note: If you checked "Employee" in Section A.8, and your former spouse performed more than 18 months of creditable
civilian Federal service, and a court awards you all or a portion of the Basic Employee Death Benefit or a survivor annuity, contact
the former employing agency of the deceased in order to complete the necessary election forms in Standard Form 3104B.
Section E - Information About the Deceased Person's Dependent Children
1a. Are there any unmarried dependent children as defined in the instructions?
Student
1b. Name(s) of unmarried dependent children
(list in order of birth)
1c. Date of birth
(mm/dd/yyyy)
1d. Child's relationship to the deceased
(child of former marriage, adopted, etc.)
1e. Age 18
or over
1f. Child's Social
Security Number
Disabled
Yes Complete items 1b-1f below No Go to Section F
2.Is there a child of the deceased not yet born?
Yes When born, send birth certificate for child to OPM No
3a. Do you (the applicant) have responsibility for all the children in Section E1?
No Complete items 3b-3d below Yes Go to item 4a
Other Specify
3b. Name and address of person having responsibility for child 3c. Name(s) of children
3d. Custodian's
Relationship to child
Legal guardian
Other Specify
Legal guardian
Other Specify
Legal guardian
Standard Form 3104
Page 2 of 4
Revised May 2013
Section F - Information About Other Heirs
4a. Has anyone applied for benefits from the Social Security Administration (SSA) for minor or disabled children of the deceased?
4b. Have you attached a copy of the SSA's Notice of Award of benefits, and/or denial of benefits, and/or disability determinations for each child?
No (Application required for payment of benefits)
No Not yet received (Forward to OPM upon receipt)
Yes
Yes
List other relatives who can inherit from the deceased as explained in the instructions.
1. Full name of relative 3. Relationship to deceased 2. Complete address
Section G - Information About the Estate of the Deceased
1.Has an executor, administrator or other official been appointed by the court to2.Full name and address of person appointed (street, city, state, ZIP code)
settle the estate of the deceased?
No Go to item 3 below Yes
3. If an executor, administrator or other official has not been court appointed, will one be appointed?
Yes No
Section H - Active Military Service (Complete ONLY if you are the surviving spouse or former spouse)
Complete if deceased was an employee or former employee at time of death. Do not complete if the deceased was retired at the time of death, since OPM already has
this information.
1.If the deceased performed active, honorable service in the Armed Forces or other uniformed services as described in the instructions, complete items 1a-b below and
attach a copy of the discharge certificate or other certificate of active military service (if available).
a. Branch of service
b. Dates of active duty
From (mm/dd/yyyy) To (mm/dd/yyyy)
2.Complete if the deceased was an employee or former employee at time of death. If any of the above listed service was performed after 12/31/56, was a deposit to the
Retirement Fund made for the service?
If the deceased was an employee at the time of death, complete and attach Standard Form 3104B which can be
Yes No
obtained from the former employing agency of the deceased.
Don't know
3a. All surviving spouses and former spouses complete.
Was the deceased receiving military retired pay at the time of death?
Yes No
3b. Did the deceased ever waive military retired pay?
Yes No
3c. Are you eligible for military survivor benefits? (Attach verification of your eligibility/ineligibility for such benefits)
Yes No
Section I - Payment Instructions
1.Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the
Department of the Treasury. See the instructions for Section I of this application and SF 3114 (Applying for Death Benefits Under the Federal Employees Retirement
System) for additional information. This does not apply to you if your permanent payment address is outside the United States in a country not accessible via direct
deposit.
Please select one of the following:
Please send my survivor annuity payments directly to my checking or savings account. (Go to item 2.)
Please send my survivor annuity payments to my Direct Express debit card. (Go to Section J.)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to Section J.)
Page 3 of 4
Standard Form 3104
Revised May 2013
Section I - Payment Instructions (Continued)
2.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)?
Yes No
3.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?
Yes
No
4. 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 verify this number.)
5.Checking or savings account number 6.What kind of account is this?
Checking Savings
7.Name and address of your financial institution
8.Telephone number of your financial institution (including area code)
Special note: 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.
1. Signature of applicant named in Section B. (Sign in ink; do not
print.)
3. Daytime telephone # (area code) 4. Email Address
3a. Best time to call you 5. Date (mm/dd/yyyy)
2. Mailing address
Warning: 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.
(18 USC 1001)
Section K - Applicant's Checklist
Attach copies of the following documents to expedite the processing of your application.
Document Title Requirement
Attached
Comments
Yes No N/A
Death certificate Certified copy required in all cases
Marriage certificate
Required if you were the spouse of the deceased at time of death (if married more
than once, provide copies of all certificates)
Child(ren)'s birth certificate
Recommended for all children for whom you are applying for benefits
Social security award
determinations
Needed for all minor children and spouse if spouse is under 60 and is currently
eligible for mother, father or disability benefits from the Social Security
Administration (SSA), based on deceased person's service. Also needed for all
children who are unmarried and are age 18 or older, but who became mentally
and/or physically disabled before age 18 and who, because of disability, are
incapable of self-support. If not submitted, the Office of Personnel Management
(OPM) will obtain the information from SSA; however, this may delay the
processing of your claim.
Court papers appointing
executor/administrator
Required if you are applying as executor or administrator of deceased person's
estate
Court papers appointing
guardian for minor or
disabled child(ren)
Required if you are applying on behalf of minor or disabled children of the
deceased and guardian has been appointed by court.
DD 214's or other military
discharge certificates
Provide if you are applying as surviving spouse or former spouse, and the deceased
was a former employee at time of death. Failure to attach the information may
delay the processing of your claim.
Page 4 of 4
Standard Form 3104
Revised May 2013
Federal Employees
Retirement System
Form approved:
Survivor Supplement
OMB number 3206-0172
Federal Employees Retirement System
Complete this form if the deceased was retired at the time of death. Attach this form to the Application for
Death Benefits, SF 3104, before forwarding it to the Office of Personnel Management (OPM).
To be completed by surviving spouse if he/she is under age 60 and the deceased had at least 5 years of creditable civilian service.
Identifying Information
Name of deceased retiree (last, first, middle initial) Date of birth (mm/dd/yyyy) Social Security Number CSA claim number
A survivor's supplement is an additional benefit to the basic survivor annuity death benefit that is equal to the lesser of:
1.The amount by which the survivor annuity that would have been payable under Civil Service Retirement System (CSRS) rules
exceeds the basic annuity payable under Federal Employees Retirement System (FERS) rules, or
2.The amount of a deemed widow/widower's Social Security benefit based on the service under FERS of the deceased.
The deceased retiree must have performed 5 years of service that could be creditable under FERS or CSRS rules, including one full
calendar year of service creditable under FERS rules.
You may be eligible for a survivor supplement if you are the surviving spouse of a retiree and you are:
1.under age 60; and
2.entitled to Social Security benefits at age 60; and
3. not presently eligible for Social Security mother, father or disability benefits based on the deceased annuitant's account.
To help us determine your eligibility for a survivor supplement, you should provide the following information:
3a. Are you eligible for Social Security disability benefits based on the deceased retiree's service?
1. Name of surviving spouse (last, first, middle initial)
3b. Do you receive Social Security disability benefits based on your own service?
2. Spouse's date of birth (mm/dd/yyyy)
3. Are you disabled?
No Go to item 4
Yes
Go to items 3a and 3b.
Yes
No Applied, but no response yet Have not applied
Applied, but no response yet Have not applied
Yes No
4.Are you eligible for Social Security mother or father benefits based on the deceased retiree's service?
Applied, but no response yet
Yes No, I have been denied these No, I know I do not qualify for these benefits as
benefits (attach photocopy ofthere are no surviving dependent children under
Have not applied
denial letter)
.
age 16 or disabled who are entitled to SSA child's
insurance benefits.
5. If you are not currently receiving Social Security mother, father or disability benefits, do you agree to notify us promptly if you are later awarded any of these benefits?
Yes No
6. Signature
7. Date (mm/dd/yyyy) 8. Telephone number (including area code)
Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices
Standard Form 3104A
Revised May 2013
PRINT
SAVE
CLEAR
Login to HandyPDF
Tips: Editig or filling the file you need via PC is much more easier!
By logging in, you indicate that you have read and agree our Terms and Privacy Policy.