Supporting Statement

OMB SUPPORTING STATEMENT

SF 3104 – Application for Death Benefits (FERS)

SF 3104B – Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death

1. Justification

1. Title 5, U.S. Code, Chapter 84, provides several types of death benefits

payable upon the death of Federal employees, former employees and annuitants covered by FERS. The type(s) of benefit(s) payable depends on the amount of creditable Federal service the deceased performed, his/her status at death (i.e., employee, former employee or annuitant), the relationship of the applicant to the deceased and in the case of annuitants, any election(s) made regarding survivor benefits.

Upon the death of an employee, a survivor annuity may be payable to a spouse, former spouse (by court order) and/or eligible dependent children. If the deceased employee completed at least 18 months of creditable service, the spouse (or former spouse by court order) is eligible for the basic employee death benefit which is payable in either a lump sum or 36 monthly installments. If the employee completed at least 10 years of creditable service, the spouse (or former spouse if payable by court order) is also eligible for a monthly survivor annuity. Children of deceased employees are eligible for a monthly survivor annuity, if the deceased employee completed 18 months of service and the child meets certain criteria. A lump sum benefit is payable to the individual entitled under 5 U.S.C. 8424(d) if no other benefits are payable.

Upon the death of an annuitant, the spouse (or former spouse) is eligible for a monthly survivor annuity if elected by the annuitant at retirement or court-ordered in the case of a former spouse. Children of deceased annuitants are also eligible for a monthly survivor annuity if certain criteria are met. A lump sum benefit may also be payable, regardless of whether a survivor is payable.

Upon the death of a former employee, the spouse who was married to the former employee at the time of his/her separation from Federal service and/or former spouse (if payable by court order) are eligible for a monthly survivor benefit or a lump sum payment of the amount in the former employee’s retirement account if the former employee completed 10 years of creditable service. If no monthly survivor annuity is payable, a lump sum benefit may be payable to the individual entitled under 5 U.S.C. 8424(d).

These benefits cannot be paid unless application for the benefits is made to the Office of Personnel Management.

2. SF 3104 is used by all survivors who apply for FERS death benefits,

including former spouses. The information collected via this application is used by the Office of Personnel Management, Federal Employees Retirement System, to determine whether a benefit is payable in the event of the death of an employee, a former employee, or an annuitant. Sufficient information must be collected to identify the deceased. Information from applicants for monthly benefits must be collected to establish their relationship to the deceased, the age of the applicant, whether the applicant could be in receipt of any other Federal benefit which would bar payment of survivor annuity, and the existence and whereabouts of minor children who are payable. Applicants for lump sum payments are asked to supply information to establish their relationship to the deceased, the existence and whereabouts of other heirs, and whether there is a court-appointed executor or administrator of the estate. Information is also collected regarding the address of the applicant.

Since the amount of the benefit depends on the amount of service performed by the deceased, information is collected from survivors of deceased employees about whether a deposit has been paid for any active military service the deceased performed after 12/31/56 and whether the deceased was receiving or had waived military retired pay. This information about military service is already available to OPM in the case of deceased annuitants.

Benefits to children are contingent upon the total amount payable to children of the deceased under Title II of the Social Security Act. Therefore, parents or guardians of minor children are asked to submit verification of entitlement or lack of entitlement to social security benefits.

SF 3104A (attached to the SF 3104), requests information from the survivor which is used by OPM to determine entitlement to a survivor annuity supplement (supplementary annuity).

SF 3104B is used by the deceased employee’s former employing agency in death-in-service cases, to supply OPM with the information necessary to support the survivor’s application for death benefits (SF 3104). The form is divided into six sections. Section 1 (Certified Summary of Federal Service) and Section 6 (Agency Information and Certification) are completed by the decedent’s employing agency’s personnel office. On the form in Section 1, the agency provides a certified history of the decedent’s Federal service to be used to determine the correct benefit(s) payable to the survivor. Section 6 contains a checklist which the agency’s payroll and personnel offices complete providing information regarding the decedent’s retirement coverage, receipt of benefits from the Office of Workers’ Compensation Programs (OWCP), and information regarding the decedent’s health and life insurance coverage. A checklist is also included informing the agency of all documentation which must be attached to the survivor’s application. The forms found in Sections 2 (Basic Employee Death Benefit), 3 (Health Benefits Election) and 4 (Information and Elections Regarding Post-1956 Military Service) are completed by both the decedent’s employing agency and the applicant(s), and Section 5 (Rollover Option Information) is completed by the applicant(s), providing OPM with certain elections which need to be made by the applicant(s) prior to the completion of their claim for benefits. The collection of this information with the Application for Death Benefits allows OPM to process claims for death benefits more quickly than if the information and elections were requested after the Application for Death Benefits was received.

The SF 3104 and the SF 3104B are separate forms since the SF 3104B is only used by individuals applying for death benefits based on the death of an employee, whereas the SF 3104 is used to apply for benefits based on the death of annuitants, employees and former employees.

3. New methods of information collection technology will do little to reduce

the burden as the information collected is detailed and can only be obtained from the respondents, who sign the application attesting to its truth, under penalty of law, to the best of their knowledge. However, these forms are available in a PDF fillable format on our website and meet our GPEA requirements.

4. OPM has the sole authority to collect this information; therefore,

duplication is minimized. Up-to-date, similar information certified by the applicant is not available.

5. Information is not collected from small business.

6. This information collection is required upon the death of an employee.

Less frequent collections would delay the award of benefits authorized by Title 5, U.S. Code, Chapter 84.

7. This information collection is consistent with the guidelines in 5 CFR

1320.6.

8. A notice of proposed information collection was published in the Federal

Register, on March 21, 2012, giving persons outside the agency an opportunity to comment on this form. No comments were received.

9. No payment or gift is provided to these respondents.

10. This information collection is protected by the Privacy Act of 1974 and

OPM regulations (5 CFR 841.108). The routine uses of disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et. seq.,

March 20, 2008).

11. This information collection does not include questions of a sensitive

nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. It is estimated that approximately 12,734 Standard Form 3104s

(Application for Death Benefits) are expected to be processed annually. The form requires approximately 60 minutes to complete including the time for reviewing instructions, getting the needed data, and reviewing the completed form. An annual burden of 12,734 hours is estimated. Approximately 4,017 SF 3104Bs (Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death) are expected to be processed annually. It is estimated that the form requires approximately 60 minutes to complete. An annual burden of 4,017 hours is estimated. The total annual burden is 16,751.

12. There is no cost to the respondent.

14. The annualized cost to the Federal government is $332,675.00. This cost

includes employees’ salary hours devoted to the program, forms cost and overhead.

15. There are no changes to the respondent burden.

15. The results of this information collection are not published.

17. It is not cost-effective to reprint the whole supply of forms to change the

OMB clearance expiration date. Therefore, we seek approval not to display the date on the form.

18. There are no exceptions to the certification statement.