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⚠️ Notice: This information collection may be referencing outdated material.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 SF 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 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SF 3104	Application for Death Benefits (FERS)	SF3104_November2010.pdf		No		Fillable Printable
Form and Instruction	SF 3104B	Documentation and Elections in Support of Application for Death Benefits when Decedent was an Employee at the Time of Death	SF3104B_November2010.pdf		No		Fillable Printable

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 %

	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

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