Form OPM 1825 OPM 1825 APPLICATION FOR U.S. FLAG RECOGNITION BENEFIT FOR DECEAS

Form Approved
OMB 3206-XXXX

APPLICATION FOR U.S. FLAG RECOGNITION BENEFIT
FOR DECEASED FEDERAL CIVILIAN EMPLOYEES
General Information and Instructions:

Complete this form and submit it to the Federal Government agency that employed the deceased at the time of
his/her death. Contact the agency if you need help to complete this form.


Public Law 112-73 authorizes a Federal executive agency head to provide a United States flag under certain
circumstances (see page 2 for eligibility information).
INFORMATION ABOUT THE DECEASED FEDERAL CIVILIAN EMPLOYEE

Name of Deceased (Last, First, Middle Initial):
Last Four Digits of Social Security Number:

Date of Death:

Cause of Death:

Death Certificate or Other Documentation Provided (if required by agency):

Yes

No

N/A

Employing Agency:

INFORMATION ABOUT THE FLAG BENEFICIARY
Name of Beneficiary (Last, First, Middle Initial):
Address (number and street or rural route, city or P.O., and ZIP Code):

Relationship to Deceased:

ELIGIBILITY
Beneficiary: I CERTIFY that I am eligible to request this benefit

Print Name: (Last, First, Middle Initial)
Signature:

Date:

Authorized Agency Official: I CERTIFY that the EMPLOYEE is eligible for this benefit.
Print Name: (Last, First, Middle Initial)
Title of Authorized Agency Official:
Date Flag Issued:
Signature:

OPM 1825
February 2013

Form Approved
OMB 3206-XXXX

Eligibility:
Employees. An authorized agency official may, upon the request of a beneficiary, provide a United States flag on
behalf of an individual who —
 was an employee of the agency; and
 died on or after December 20, 2011, of injuries incurred in connection with such individual’s employment
with the Federal Government suffered as a result of a criminal act, an act of terrorism, a natural disaster,
or other circumstance as determined by the President.
Beneficiaries. An authorized agency official may furnish a United States flag upon the request of a beneficiary of a
deceased eligible employee in the following order of precedence:
 widow or widower;
 if none, to a child (including step, foster, or adopted child), according to age (i.e., oldest to youngest);
 if none, to a parent (including step, foster, or adoptive parent);
 if none, to a sibling (including step, half, or adopted sibling), according to age (i.e., oldest to youngest);
 if none, to any individual related by blood or close family affiliation.

Privacy Act Notice:
The Office of Personnel Management (OPM) will not disclose information collected on this form to any source
other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations
1.576 for routine uses. Your obligation to respond is required to obtain or retain benefits. Giving us the SSN
account information is voluntary. Refusal to provide the Employee’s SSN by itself will not result in the denial of
benefits. OPM will not deny an individual benefits for refusing to provide his or her SSN unless a Federal Statute
of law in effect prior requires the disclosure of the SSN to January 1, 1975, and still in effect. The requested
information is considered relevant and necessary to determine entitlement to benefits under the law. The
responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
Public Burden Information:
Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding the burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
Reports and Forms Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room
5415, Washington, D.C. 20415. Do not send your completed form to this address.

OPM 1825
February 2013