SF3104_November2010_Markup

Application for Death Benefits
Federal Employees
Retirement System

Form approved:
OMB number 3206-0172

Federal Employees Retirement System

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. You can also access SF 3114 over the Internet at www.opm.gov/retire/pubs/pamphlets/list.asp.
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. 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.)

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.

8.

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.

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").

See the pamphlet entitled, Applying for Death
Benefits Under the Federal Employees Retirement
System, SF 3114 to help you determine which block
to check.

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

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

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Instructions
Standard Form 3104
Revised November 2010
Previous editions are not usable.

•

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.

1b. Attach a copy of the birth certificate for each child
for whom you are applying.
1d. 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.
1e. If the unmarried dependent son or daughter is 18 or
over, state whether he or she is a full-time student
and/or disabled.

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.

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.

3d.

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.

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
1a. 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:
•

•

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:

was under age 18 at the time of the deceased person's death, including any:
1.

adopted child, and/or

2.

stepchild, and/or

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.

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

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.

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•

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

•

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 desendants 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.

Instructions
Standard Form 3104
Revised November 2010

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

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.
3.

Section H - Active Military Service
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.

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.

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.

Section K - Applicant's Checklist
Use this section of the application to ensure that all required
supporting documentation is attached.
SF 3104A
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.

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.
2.

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

SF 3104B
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.

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

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 estimate 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), Retirement & Benefits Publications Team (3206-0172), Washington, D.C. 20415-3430. 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.
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Instructions
Standard Form 3104
Revised November 2010

Form Approved
OMB No. 3206-0172

Application for Death Benefits
Federal Employees Retirement System

Federal Employees
Retirement System

Section A - Information About the Deceased
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?
8.

Yes

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)

Employee
9.

7b. OWCP claim number

No

Complete SF 3104B, which can be obtained from the
deceased person's former employing agency.

Former
employee

Retiree

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

Name of deceased person's spouse at time of death (if not married at time of death write "none")

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

10b. How did each marriage end?

Death

Divorce/annulment

Death

Divorce/annulment

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

Section B - Information About the Applicant
1.
4.

Your full name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

No

I am applying for benefits as (check all boxes that apply):

Widow(er)
complete Section C below
Designated beneficiary (attach copy of designation, if available)
Parent of decedent (Each parent should complete a separate
application. If one parent is deceased, attach a copy of the death certificate.)
6.

3.

Are you a citizen of the United States of America?

Yes
5.

2.

Executor or administrator of estate (attach copy of court
order)
Former spouse
Complete Section D on page 2
Child (or as guardian of minor or disabled child)
Other (specify):

Did you cash any check(s) issued to the deceased or did you withdraw funds paid by direct
deposit from the deceased's savings or checking account after the date of death?

No
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
3.

2.

Date of marriage (mm/dd/yyyy)

Other (explain)

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?

No
Yes

Go to item 5 below
Complete items 4b-4e below

4b. Name of deceased former spouse

4c. Date of birth (mm/dd/yyyy)

4d. Name of retirement system (e.g. Civil Service, Foreign Service)

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

Page 1 of 4

Standard Form 3104
Revised November 2010

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

Go to item 4a

Yes

Go to item 3b

3b. Give name and address of agency where you send health benefit premiums:

4a. Have you married again since your marriage to the deceased?

No

Go to item 5a

Yes

4b. Date of first marriage after marriage to deceased ended (mm/dd/yyyy)

Go to item 4b

5a. Have you ever applied for a survivor annuity based on the Federal service of a
deceased spouse or former spouse other than the one named on page 1, Section A1?

No

Go to item 6

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.)
6.

Complete items
5b-5e below

Yes

5e. Claim number assigned to you by retirement system in item 5d.

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
1b. Name(s) of unmarried dependent children
(list in order of birth)

Complete items 1b-1f below

1c. Date of birth
(mm/dd/yyyy)

1d. Child's relationship to deceased
(child of former marriage, adopted, etc.)

No

Go to Section F

1e. Age 18
or over

1f. Child's Social
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

No

3a. Do you (the applicant) have responsibility for all the children in Section E1?

No
3b. Name and address of person having responsibility for child

Complete items 3b-3d below
3c. Name(s) of children

Yes

Go to item 4a

3d. Custodian's
Relationship to child

Legal guardian
Other

Specify

Legal guardian
Other

Specify

Legal guardian
Other

Page 2 of 4

Specify

Standard Form 3104
Revised November 2010

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)

Yes

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?

Not yet received (Forward to OPM upon receipt)

No

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
3.

Go to item 3 below

2.

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

Yes

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).
a.

2.

b.

Branch of service

Dates of active duty

From (mm/dd/yyyy)

To (mm/dd/yyyy)

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?

Yes

Don't know

No

If deceased was an employee at the time of death, complete and attach Standard Form 3104B 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?
3b. Did the deceased ever waive military retired pay?

Yes

No

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 November 2010

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)?

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?

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

7.

Name and address of your financial institution

8.

Telephone number of your financial institution (including area code)

Yes

Yes

6.

No

No

What kind of account is this?

Checking

Savings

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 telephone # (area code)

3a. Best time to call you
2.

Mailing address

4.

Email Address

5.

Date (mm/dd/yyyy)

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)

Attached
Yes No N/A

Comments

Child(ren)'s birth certificate Recommended for all children for whom you are applying for benefits

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

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 November 2010

Form approved:
OMB number 3206-0172

Survivor Supplement
Federal Employees Retirement System

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?

No
Yes

2.

3a.

Spouse's date of birth (mm/dd/yyyy)

Are you eligible for Social Security disability benefits based on the deceased retiree's service?

Go to item 4
Go to items 3a and 3b.

Yes

No

Applied, but no response yet

Have not applied

No

Applied, but no response yet

Have not applied

3b. Do you receive Social Security disability benefits based on your own service?

Yes
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.

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?

6.

Signature

Yes

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

7.

Date (mm/dd/yyyy)

No
8. Telephone number (including area code)

Standard Form 3104A
Revised November 2010