Form Exchange Form 1450 Exchange Form 1450 Application for Payment of Survivor Annuity

OMB NO 0702-xxxx
OMB approval expires
MMM DD, YYYY

ARMY AND AIR FORCE EXCHANGE SERVICE

Certificate No.

APPLICATION FOR PAYMENT OF SURVIVOR ANNUITY
DEATH IN SERVICE
Page 1
INSTRUCTIONS
This survivor annuity application is completed by a widow or widower of an Exchange associate to begin the process of obtaining
payments.
Page 1 of this application should be reviewed prior to completion of information on page 2.
Information needed to complete this form may include birth certificates, marriage licenses, death certificates, social insurance awards or
letter of declination from the Department of Health, Education, and Welfare. Please be prepared to submit copies of these documents
with the submission of the completed form.
Questions should be directed to the Exchange Headquarters Human Resource Support Center Directorate (HRSC) at 800-508-8466 or
through e-mail to [email protected].
Once the completed form is signed and witnessed, it should be returned with copies of the applicable certificates as directed to HRSC for
final processing.

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AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing
the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark
Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0702-XXXX). Respondents should be aware that notwithstanding any other
provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently
valid OMB control number.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.

Responses should be sent to your local Exchange HR Representative or to the Treasury Benefit department at the Army and Air Force Exchange
Service, 3911 South Walton Walker Blvd., Dallas, TX 75236-1598.

PRIVACY ACT STATEMENT

AUTHORITY: Title 10 U.S.C. 3013, “Secretary of the Army”; Title 10 U.S.C. 8013, “Secretary of the Air Force”; Title 42 U.S.C. 659, “Consent
by United States to income withholding, garnishment, and similar proceeding for enforcement of child support and alimony obligations”; 31 CFR
285.11, “Administrative Wage Garnishment”; DoD Directive 7000.14-R, Volume 13 and 16, “DoD Financial Management Regulation”;
Department of Defense Instruction (DoDI) 1400.25, Volume 1408, “DoD Civilian Personnel Management System: Insurances and Annuities for
Nonappropriated Fund (NAF) Employees”; Army Regulation 215-8/AFI 34-211(I), “Army and Air Force Exchange Service Operations”; and E.O.
9397 (SSN), as amended.

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PRINCIPAL PURPOSE(S): Information collected is to provide the basis for computing survivor pay deductions upon the death in service of an
Exchange employee.

ROUTINE USE(S): Your records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding DoD “Blanket Routine
Uses” published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Information may be disclosed to former spouses
and/or survivors, to federal, state, or local child support agencies for purposes of assisting the agencies in the discharge of their responsibilities
under federal and state law.
DISCLOSURE: Voluntary, however, failure to provide all the requested information may result in the denial of your application for benefits.

SYSTEM OF RECORD NOTICE: AAFES 0703.07 “Employee Pay System Records”;
http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570129/aafes-070307.aspx
AAFES 0903.06 “Personnel Management Information System”;
http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570130/aafes-090306.aspx

ARMY AND AIR FORCE EXCHANGE SERVICE

APPLICATION FOR PAYMENT OF SURVIVOR ANNUITY
DEATH IN SERVICE
Page 2
NOTICE TO APPLICANT:
The amount of survivor annuity payable, if any, is determined by computation as described in the Retirement Plan Booklet. The formula requires that the amount otherwise developed be
reduced by an amount equal to any widow or widower’s income benefits including a parent’s income benefit as the mother or father of a minor child or children, payable under the Social
Security Act.

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You are responsible for and required to furnish Headquarters Exchange with the decedent’s Statement of Earnings or applicant’s award from the Social Security Administration before a survivor
annuity can be made payable. You must also promptly furnish Headquarters Exchange a copy of each notice effecting the commencement, discontinuance, or other change in your Social
Security income so that necessary adjustments may be made in the amount of your survivor annuity.

Eligibility: The surviving widow or widower of a participate may be eligible to receive a survivor annuity on the death of the employee while actively employed when the following conditions are
met:

a.
b.

The employee has completed at least 18 months credited civilian service.
The widow or widower has been married to the employee at least 1 year immediately preceding his(her) death or to be the parent of a child born of the marriage with the employee

The amount and duration of benefits will be described in the Plan.

SOCIAL SECURITY No.

NAME OF EMPLOYEE (Last, First, Middle Initial)

EXCHANGE

ANNUITY FOR
Widow
Widower

DECEASED WAS CONTINOUSLY EMPLOYED (ATTACH COPY OF
DEATH CERTIFICATE)
FROM:

DATE OF DEATH:

DID THE EMPLOYEE SERVE IN THE ARMED
SERVICES?

YES

ATTACH COPIES OF PERSONNEL ACTIONS WHICH REPRESENT THE HIGHEST (3) YEARS OF EARNINGS.
VACATION AND SICK LEAVE BALANCES AT TIME OF DEATH AND A COPY OF THE SEPARATION ACTION.

IF YES, ATTACH A COPY OF DISCHARGE/SEPARATION CERTIFICATE. IF EMPLOYEE IS RETIRED MILITARY ATTACHED A
COPY OF MILITARY ORDERS.

NO

NAME OF SURVIVING WIDOW /WIDOWER

U.S. CITIZEN

YES

BIRTH DATE (ATTACH
COPY OF BIRTH
CERTIFICATE)

SOCIAL SECURITY NO.

ADDRESS (STREET, CITY, STATE AND ZIP CODE)

NO

MARRIAGE DATE (ATTACH COPY
OF MARRIAGE CERTIFICATE)

IS THE WIDOW OR WIDOWER THE PARENT OF A CHILD/CHILDREN BORN OF MARRIAGE WITH THE
DECEASED?
YES

NO

ATTACH A COPY OF WIDOW OR WIDOWER’S CERTIFICATE OF SOCIAL INSURANCE AWARD OR LETTER OF
DECLINATION FRM THE DEPARTMENT OF HEALTH, EDUCATION AND WELFARE.

THE WIDOW OR WIDOWER IS THE PARENT OF THE FOLLOWING UNMARRIED CHILDREN, UNDER 18 YEARS OF AGE, OF THE EMPLOYEE. (ATTACH COPY OF BIRTH
CERTIFICATE FOR EACH CHILD LISTED.)

NAME

BIRTH DATE

RELATIONSHIP

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CERTIFICATE OF SUVIVOR: I CERTIFY THAT THE INFORMATION ON THIS FORM IS
TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

_________________________________
WIDOW / WIDOWER SIGNATURE

NAME

BIRTHDATE

RELATIONSHIP

CERTIFICATION OF CONTRACT HOLDER: I CERTIFY THAT THE INFORAITON ON THIS
FORM IS CORRECT AND THAT SUITABLE BIRTHDATE(S) EVIDANCE AND MARRIAGE
EVIDENCEHAVE BEEN SUBMITTED AND VERIFIED.

________________________________
_____________________
WIDOW / WIDOWER SIGNATURE
DATE COMPLETED
COMPLETE ONLY IF APPLICANT IS THE SURVIVING SPOUSE OF AN EMP MEMBER

_____________________
DATE COMPLETED

RELEASE CLAUSE: “IN CONSIDERATOIN OF THE ARMY AND AIR FORCE OBTAINING A GUARANTEED ANNUITY FROM THE AETNA LIFE INSURANCE COMPANY TO PROVIDE THE
BENEFITS TO WHICH I AM ENTITLED UNDER GROUP ANNUITY CONTRACT #185 GAC, I HERBY, ON BEHALF OF MYSELF, MY BENEFICIARY, HEIRS, EXECUTORS,
ADMINISTRATORS AND ASSIGNS, RELEASE AND FOREVER DISCHARGE THE JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY AND ARMY AND AIR FORCE EXCHANGE
SERVICE FROM ANY AND ALL RIGHT, TITLE AND INTEREST WHICH I EVER HAD, NOW HAVE, OR AT ANY TIME IN THE FUTURE MAY HAVE IN OR TO ANNUITIES AND BENEFITS
AT ANY TIME PROVIDED UNDER GROUP ANNUITY CONTRACT #185 GAC ISSUED BY JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY TO ARMY AND AIR FORCE
ECXHANGE SERVICE BY REASON OF THE CONTRIBUTIONS OF MY DECEASED SPOUSE AND THE CONTRIBUTIONS OF THE EMPLOYER MADE THEREUNDER.”

WITNESS SIGNATURE

EXCHANGE FORM 1450-018 (2016 DRAFT)

DATE

SURVIVOR SIGNATURE

STATE OF RESIDENCE