Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0172 can be found here:

Documents and Forms

Document Name Document Type
Form 3104 Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form
3104 Application for Death Benefits sf310408-02.pdf Form
SF 3104B Documentation and Elections in Support of Application wh 033104B.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 843

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3104	Application for Death Benefits	sf310408-02.pdf		No		Fillable Printable
Form	SF 3104B	Documentation and Elections in Support of Application when Deceased was an Employee at the Time of Death	033104B.pdf		No		Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title: OPM/Central-1	FR Citation: 65 FR 25775

Number of Respondents: 13,366	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	13,366	2,519	10,847
Annual IC Time Burden (Hours)	13,366	2,519	10,847
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.