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
ICR 199810-3206-004
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⚠️ Notice: This information collection may be outdated.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
The Application for Death
Benefits/FERS (SF-3104) will be 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.
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.