Form 3104 Application for Death Benefits

Application for Death Benefits
Federal Employees Retirement System

Form approved:
OMB number 3206-0172

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. Customers within local calling distance to Washington, DC must contact OPM on 202-606-0500. You can also request
SF 3114 over the Internet at www.opm.gov/retire/html/library/fers.html.
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 the Office of Personnel Management, Federal Employees Retirement System, 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
(?).

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.

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 retirement benefits, show the CSA number (retirement claim
number).

7.

Recurring payments from the Office of Workers'
Compensation Programs, U.S. Department of Labor
(OWCP) 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 had applied for or received benefits from
the OWCP based on an illness or injury resulting
from a condition of employment within the last two
years, indicate here. The OWCP claim number
appears on the U.S. Treasury checks and 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
Office of Personnel Management
CSRS/FERS Handbook for Personnel
and Payroll Offices

NSN 7540-01-249-5573
3104-106

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 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 affidavits from persons who are in a position to know the
facts which clearly show: (1) the relationship

Previous editions are not usable.

Standard Form 3104
Revised August 2002

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 certificate, deeds, immigration records, insurance policies, 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
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:

•

is between ages 18 and 22 and who is unmarried
and a full-time student in school.

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.
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.
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:

1.

adopted child, and/or

2.

stepchild, and/or

•

Widow(er) (unless named in Section C);

3.

recognized child born out of wedlock who
lived with the deceased in a regular parentchild 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.

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.

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 selfsupport. Attach a copy of the Social Security
Administration's determination of disability (prior
to age 18) for disabled child(ren) over age 18.

Section G - Information About the Deceased
Person's Estate
1.

by completing the election form contained in Documentation 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 information regarding this deposit.

If someone was named as executor or administrator
in the deceased person's will, but hasn't been
appointed by the court, check "No." If you have been
appointed by a court, attach a copy of the court
appointment.

3.

Section H - Active Military Service

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 67, Title 10,
(formerly title III) of Public Law 80-810 (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 verifying the award was based on one of the above reasons.

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.

2.

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, 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 the deceased
was a retiree, OPM already has information about
his/her military service.

Indicate whether the deceased ever received or applied for
military retired pay.

Section K - Applicant's Checklist
Use this section of the application to ensure that all required
supporting documentation is attached.

SF 3104A

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.

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.

Persons who performed active military service after
December 31, 1956, must pay or have paid a deposit
to receive credit under the Federal Employees Retirement System (FERS) for the military service.

SF 3104B

If the deceased was an employee at the time of death,
you may pay or complete the payment of the deposit

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 think 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), OPM Forms Officer (3206-0172), Washington, D.C. 20415-7900. 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.

Application for Death Benefits

Form Approved
OMB No. 3206-0172

Federal Employees 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 (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 deceased person's employment status 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 deceased person's former employing agency.

Former
Retiree
employee
9. Name of deceased person's spouse at time of death (if not married at time of death write "none")
Employee

10a. Name of deceased person's spouses from all former
marriages

10b. How did each marriage
end?
Death

Divorce/annulment

Death

Divorce/annulment

If you are the surviving spouse,
complete SF 3104A (attached)

10c. Date each marriage ended
(mm/dd/yyyy)

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):
Executor or administrator of estate (attach copy of
court order)
Widow(er)
complete Section C below
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
Child (or as guardian of minor or disabled child)
application. If one parent is deceased, attach a copy of the death
Other (specify):
certificate.)
6. Did you cash any check(s) issued to the deceased or did you withdraw funds paid by direct
No
deposit from the deceased's savings or checking account after the date of death?
Yes

Section C - Information About the Deceased Person's Spouse
(Complete if you are the widow[er].)

1. Marriage performed by
Clergy/Justice of the Peace
Other (explain)
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?
4b. Name of deceased former spouse
4d. Name of retirement system (e.g. Civil Service, Foreign Service)

2. Date of marriage (mm/dd/yyyy)

No
Go to item 5 below
Yes Complete items 4b-4e below
4c. Date of birth (mm/dd/yyyy)
4e. Claim number (assigned to you
by retirement system in item 4d.)

5. If you will be receiving monthly payments, P.L. 104-134 requires that you be paid by direct deposit into a checking or savings account
if possible. See Section I.

Office of Personnel Management
CSRS/FERS Handbook for Personnel
and Payroll Offices

NSN 7540-01-249-5573
3104-106

Page 1 of 4

Standard Form 3104
Revised August 2002

Section D - Information About the Deceased Person's Former Spouse
(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 deceased person's Federal Employees Retirement System (FERS) retirement
or survivor benefits?
Yes, on record at OPM
Yes, attached
No
3a. Are you paying for Federal Employees Health Benefits
coverage to a former employing office?

No
3b. Give name and address of agency where you send health benefit premiums:

Go to item 4a

Yes

Go to item 3b

4a. Have you married again since your marriage to the deceased?
4b. Date of first marriage after marriage to 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 deceased spouse or former
Complete items
spouse other than the one named on page 1, Section A1?
5b-5e below
No
Go to item 6
Yes
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.

6. If you will be receiving monthly payments P.L. 104-134 requires that you be paid by direct deposit into a checking or savings account
if possible. See 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 deceased person's former employing agency 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?
Yes
Complete items 1b-1f below
No
Go to Section F
1b. Name(s) of unmarried dependent
1c. Date of birth 1d. Child's relationship to deceased (child 1e. Age 18 1f. Child's Social
children (list in order of birth)
(mm/dd/yyyy)
of former marriage, adopted, etc.)
or over
Security Number
Student Disabled

2. Is there a child of the deceased not yet born?
Yes
When born, send birth certificate for child to OPM
3a. Do you (the applicant) have responsibility for all the children in Section E1?
No
Complete items 3b-3d below
3b. Name and address of person having responsibility for child

3c. Name(s) of children

No
Yes
Go to item 4a
3d. Custodian's Relationship to child
Legal guardian
Other
Specify
Legal guardian
Other
Specify
Legal guardian
Other
Specify

Page 2 of 4

Standard Form 3104
Revised August 2002

4a. Has anyone applied for benefits from the Social Security Administration (SSA) for minor or disabled children of the
deceased?
No
(Application required for payment of benefits.)
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
Not yet received (Forward to OPM upon receipt.)

Yes
Yes

Section F - Information About Other Heirs
List other relatives who can inherit from the deceased as explained in the instructions.
1. Full name of relative
2. Complete address

3. Relationship to deceased

Section G - Information About the Deceased Person's Estate
1. Has an executor, administrator or other official been
appointed by the court to settle the estate of the deceased?
No

Go to item 3 below

2. Full name and address of person appointed (street, city,
state, ZIP code)

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 service 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).
b. Dates of active duty
From (mm/dd/yyyy)
To (mm/dd/yyyy)

a. Branch of service

2. Complete if 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 deceased was an employee at the time of death, complete and attach Standard Form 3104B
Yes
Don't know
No
which can be obtained from the deceased person's former employing agency.
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 - Direct Deposit
1. Public Law 104-134 requires that most Federal payments be paid by Direct Deposit through Electronic Funds Transfer (EFT) into a
savings or checking account at a financial institution. However, if receiving your payment electronically would cause you a financial
hardship, or a hardship because you have a disability, or because of a geographic, language or literacy barrier, you may invoke your
legal right to a waiver of the Direct Deposit requirement, and continue to receive your payment by check. Therefore, you must select
one of the following:
Please send my annuity payments directly to my checking or savings account. (Go to item 2.)
Receiving my payment(s) electronically would cause me a financial hardship, or a hardship because of a disability, or because of a
geographic, language or literacy barrier. I hereby invoke my legal right to a waiver of the Direct Deposit requirements of Public Law
104-134. Please send me my payment(s) by check. (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.)
Page 3 of 4

Standard Form 3104
Revised August 2002

Section I - Direct Deposit (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 tele.# (area code)

4. Date (mm/dd/yyyy)

Best time to call you
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

Death certificate

Certified copy required in all cases

Marriage certificate

Required if you were spouse of deceased at time of death (if married more
than once, provide copies of all certificates)

Child(ren)'s birth
certificate

Social security award
determinations

Court papers appointing
executor/administrator
Court papers appointing
guardian for minor or
disabled child(ren)
DD 214's or other
military discharge
certificates

Attached
Yes No N/A

Comments

Recommended for all children for whom you are applying for benefits
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.
Required if you are applying as executor or administrator of deceased
person's estate
Required if you are applying on behalf of minor or disabled children of
deceased and guardian has been appointed by court.
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 August 2002

Form Approved
OMB No. 3206-0172

Survivor Supplement
Federal Employees Retirement System

Complete this form if 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 deceased's service under FERS.
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:
1. Name of surviving spouse (last, first, middle initial)
3. Are you disabled?

2. Spouse's date of birth (mm/dd/yyyy)
3a. Are you eligible for Social Security disability benefits based on the deceased
retiree's service?

No
Go to item 4
Yes
No
Applied, but no response yet
Go to items 3a and 3b.
Yes
3b. Do you receive Social Security disability benefits based on your own service?
Applied, but no response yet
Yes
No
4. Are you eligible for Social Security mother or father benefits based on the deceased retiree's service?
Yes

No, I have been denied these
benefits (attach photocopy of
denial letter).

No, I know I do not qualify for these benefits
as there are no surviving dependent children
under age 16 or disabled who are entitled to
SSA child's insurance benefits.

Have not applied
Have not applied

Applied, but no response yet
Have not applied

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

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Standard Form 3104A
Revised August 2002