Information Collection

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

IC 33651 under ICR 201006-3206-004 · OMB 3206-0172.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SF 3104 Application for Death Benefits (FERS) 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 and Instruction
Form SF 3104B Documentation and Elections in Support of Application for Death Benefits when Decedent was an Employee at the Time of Death 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 and Instruction
SF 3104 Application for Death Benefits (FERS) SF3104_November2010.pdf	Form and Instruction
SF 3104B Documentation and Elections in Support of Application fo SF3104B_November2010.pdf	Form and Instruction
SF3104B_November2010_Hi-Lights.pdf SF 3104B_November 2010_Hi-Lights	IC Document
SF3104B_May2003_Hi-Lights.pdf SF3104B_May2003_Hi-Lights	IC Document
SF3104_November2010_Hi-lights.pdf SF3104_November2010_Hi-lights	IC Document
SF3104_April2002_Hilight.pdf SF3104_April2002_hilight	IC Document
SF3114_August2003_Hilight.pdf SF3114_August2003_Hilight	IC Document
SF3114_September2008_Hi-light.pdf SF3114_September2008_Hi-light	IC Document
SF3114_September2008.pdf SF3114_September2008	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SF 3104				No		Fillable Printable
Form and Instruction	SF 3104B				No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title: OPM/Central-1

FR Citation: 73 FR 15013

Number of Respondents: 16,751

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,751	3,385	13,366
Annual IC Time Burden (Hours)	16,751	3,385	13,366
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SF 3104B_November 2010_Hi-Lights		06/22/2010
SF3104B_May2003_Hi-Lights		06/22/2010
SF3104_November2010_Hi-lights		06/22/2010
SF3104_April2002_hilight		06/22/2010
SF3114_August2003_Hilight		06/22/2010
SF3114_September2008_Hi-light		06/22/2010
SF3114_September2008		06/22/2010

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

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