Application for Death Benefits/Federal Employees Retirement System Documentation and Elections in Support of Application for Death Benefits When Deceased was an Employee at the Time of Death
ICR 199507-3206-003
OMB: 3206-0172
Federal Form Document
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 3206-0172 can be found here:
Application for Death
Benefits/Federal Employees Retirement System Documentation and
Elections in Support of Application for Death Benefits When
Deceased was an Employee at the Time of Death
The application for death
benefits/FERS (SF 3104/3104A) are used to apply for benefits under
the Federal Employee's Retirement System based on 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.
Documentation and elections in support of application for death
benefits when deceased was an employee at the time of death (SF
3104B) is used by applicants for death benefits under FERS if the
deceased was a Federal employee at the time of death.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.