SF 2800 CSRS Application for Death Benefits

Civil Service
Retirement System

Application for Death Benefits
Civil Service Retirement System
This application is for use by persons applying for benefits which may be payable under the Civil Service Retirement System (CSRS)
because of the death of an employee, former employee, or retiree who was covered by CSRS 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 Civil Service
Retirement System” SF 2800-1, 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 write to the Office of
Personnel Management at OPM, P.O. Box 45, Boyers, PA 16017-0045, call OPM’s Retirement Information Office at 1-888-767-6738, or
send us e-mail at [email protected].
If the deceased was an employee at the time of death, send your completed application, with any 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, P.O. Box 45, Boyers, PA 16017-0045. If your address changes before we give you a survivor annuity claim
number, notify us in writing and give 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, notify us of the change by calling or writing as described above.
Be sure to refer to your claim number.

Instructions For Completing Application

Section B - Information About the Applicant

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 (?).

5.

The following additional information should help you to answer
those questions on the application which are not entirely selfexplanatory.

Section A - Information About the Deceased
6.
7.

8.

If deceased had ever applied for or received retirement
benefits, show the retirement claim number.
Recurring payments from the Office of Workers’
Compensation Programs, U.S. Department of Labor (OWCP)
and CSRS survivor annuity benefits 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 received 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.
See the pamphlet entitled “Applying for Death Benefits
Under the Civil Service Retirement System” to help you
determine which block to check.

10. If the deceased had no former marriage, write “none.” Attach
copies of death certificates and complete copies of court
orders of divorce or annulment if these occurred on or after
May 7, 1985. If you are the spouse of the deceased and you
and the deceased were married more than one time, be sure to
show the date your prior marriage(s) ended.

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

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.)

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”).
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 and clearly state: (1) the
relationship 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
spouses 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.

Standard Form 2800
Revised June 2018
Previous editions are not usable.

In addition, your own affidavit is required. It should state:
(1) the date on which, and the State in which, you and your spouse
mutually agreed to become spouses; (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
that ended it); and (3) any other facts you believe will help prove
you were spouses. You may also submit other documents which
show a marital relationship such as a naturalization certificate,
deeds, immigration records, insurance policies, passports, child’s
birth certificate, income tax returns, etc.
2.

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:

•
•

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

•

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 administrator as described
in Section G, list other relatives who can inherit from the
deceased. The people you list must be blood kin of the
deceased.

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.

Section F - Information About Other Heirs

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:
was under age 18 at the time of the deceased person’s
•
death, including any:
--

adopted child, and/or

--

stepchild, and/or

--

recognized child born out-of-wedlock who lived
with the deceased in a regular parent-child
relationship, and/or

•

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

--

•

•

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 age 18 or older and unmarried, but who became
mentally and/or physically disabled before age 18
and who, because of the disability, is incapable of
self-support.
is between ages 18 and 22, unmarried, and a full-time
student in a recognized educational institution.

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.
Adult children may submit separate applications if they
want separate payments made to them.
The mother of the unborn child, the legal guardian or the
person responsible for the child should send us the birth
certificate, when available.

2.

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.

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 descendants of deceased
children to the deceased, for example, John and Mary,
children of deceased son John, and Sue, child of deceased
daughter Ann);

If someone was named as executor or administrator in the
deceased person’s will, but is not appointed by a court,
check “no.” If you have been appointed by a court, attach a
copy of the court appointment.

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 OPM already has
this information.
1.

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 you have a copy of the deceased person’s DD 214s or
other discharge certificate(s) showing the dates of active
duty and the deceased was an employee at the time of death,
you should attach it (them) to your application.

2.

Persons who performed active military service after
December 31, 1956, must pay or have paid a deposit to
receive credit 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 by
completing the election form contained in SF 2800A, which
can be obtained from the agency where the deceased was
last employed. The agency can provide you with more
information about this deposit.

Standard Form 2800
Revised June 2018

3.

Indicate whether the deceased ever received or applied for
military retired pay.
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 title
10, U.S. Code Sections 12731 through 12739, (formerly
Chapter 67, title 10) (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 to show that the award was based
on one of the above reasons.

Section J - Certification
1.

Sign your name in ink. Please note that OPM will not accept
the signature of someone who has a power of attorney for
the applicant named in Section B. A court-appointed
fiduciary can apply on behalf of the applicant, provided a
court-certified copy of the court appointment is attached to
the application for death benefits. If there is no courtappointed fiduciary and the applicant is not competent, a
relative or person responsible for the applicant may sign.
OPM will arrange later for the appointment of a
representative payee for the person named in Section B.

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

SF 2800A
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 Standard Form 2800A, which
can be obtained from the deceased person’s employing agency.
Instructions for completing SF 2800A are contained on the form
itself.

Privacy Act Statement
Pursuant to 5 U.S.C.§ 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to
collect the information requested on this form by 5 U.S.C. Chapter 83, Sections 8341 and 8342. OPM is authorized to collect your Social Security number by Executive
Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008). Purpose: The information collected on this form is used by the Civil Service
Retirement System to authorize payment of benefits in the event of the death of an employee, a former employee or an annuitant. Routine Uses: The information requested
on this form may be shared externally as a "routine use" to other Federal agencies and third-parties when it is necessary to process your application. For example, OPM may
share your information with other Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain information necessary for
determining your eligibility for refund, or to report income for tax purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a
violation or potential violation of civil or criminal law. A complete list of the routine uses can be found in the OPM/CENTRAL 1 Civil Service Retirement and Insurance
Records system of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide Information: Providing this information to OPM is voluntary.
However, if you fail to provide this information, OPM may be unable to process your application for death benefits.

Public Burden Statement
We estimate this form takes an average of 45 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 Services Publications Team (3206-0156), Washington, D.C. 20415-0001. Completed application forms should not be sent to this
address. The OMB Number 3206-0156, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Standard Form 2800
Revised June 2018

Form Approved:
OMB No. 3206-0156
Civil Service
Retirement System

Application for Death Benefits
Civil Service Retirement System

Section A - Information About the Deceased
1.

Full name of deceased (last, first, middle)

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 Numer

5.

List any other names the deceased used (such as 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
7b. OWCP claim number
(OWCP), Department of Labor?
No
Yes
8. What was deceased person's employment status at time of death (see pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System")
Employee
Complete SF 2800A, which can be obtained from the deceased person's former employing agency.
9. 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?
Divorce/annulment

Former employee

10c.

Retiree

Date each marriage ended

A court has awarded this
former spouse a survivor
benefit.

Death
Divorce/annulment

A court has awarded this
former spouse a survivor
benefit.

Death

Section B - Information About the Applicant
1.

Your full name (last, first, middle)

2.

4a. Are you a citizen of the United States of America?
5.

Date of birth (mm/dd/yyyy)

3. Social Security Number

4b. What country are you a citizen of?

Yes
No
I am applying for benefits as (check all boxes that apply):
Designated beneficiary (attach copy of designation, if available)

Widow(er)

Child (or descendant of deceased child or guardian of minor or disabled child)

Former spouse

Parent of decedent (Each parent should complete a separate application. If one
parent is deceased, attach a copy of the death certificate.)

Executor or administrator of estate (attach copy of court order)

Complete Section C below
Complete Section D below

Other (specify):
6.

Did you cash any check(s) issued to the deceased after the date of death, did you withdraw from the deceased's savings or checking account retirement monies paid by
Direct Deposit after the date of death, or did you withdraw from or use a Direct Debit card belonging to the deceased?

Any uncashed checks must be returned to the Treasury.
It is a violation of law for anyone to withdraw payments deposited after the death of the deceased
named above.
Section C - Information About the Deceased Person's Spouse (Complete if you are the widow(er).)
No

1.

Yes

Marriage performed by

2.

Clergy/Justice of Peace
Other (explain)
3a. Have you remarried after your spouse died?

Date of marriage (mm/dd/yyyy)

3b. Date of remarriage (mm/dd/yyyy)

No
Yes
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
Go to Section E
4b. Name of deceased former spouse

Yes

Complete items 4b-4e below
4c. Date of birth (mm/dd/yyyy)

4d. Name of retirement system (for example, Civil Service, Foreign Service)

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

4e. Claim number (assigned to you by
retirement system in item 4d.)

Page 1 of 4

Standard Form 2800
Revised June 2018

Section D - Information About the Deceased Person's Former Spouse
(Complete if you are the widow(er).)
1a. Date of marriage to the deceased (mm/dd/yyyy)

1b. Date of divorce or annulment from the deceased (mm/dd/yyyy)

2.

Is there a court order awarding you any portion of the deceased person's CSRS retirement or survivor benefits?

3.

Are you paying for Federal Employees Health Benefits coverage to a former employing office?

Yes, on record at OPM
No

Go to item 4a

Yes, attached
Yes

No
Go to item 3b

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

4a. Have you married since your marriage to the deceased ended?
No

Go to item 5a

Yes

4b. Date of first marriage after marriage to deceased ended
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 A.1?
No

Go to item 6

Yes

Complete items 5b-5e below

5b. Name of deceased former spouse

5c. Date of birth (mm/dd/yyyy)

5d. Name of retirement system (for example, Civil Service, Foreign Service, etc.)

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

6.

If you checked "Employee" in Section A.8, your former spouse performed more than 18 months of creditable civilian Federal service, you were married to the deceased
for at least 9 months, and a court awarded you all or a portion of the survivor annuity, contact the deceased person's employing agency in order to complete the
necessary election in Standard Form 2800A.

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)

2.

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

Complete items 1b-1f below

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

No

Go to Section F

1e. Age 18
1f. Child's Social
or over
Security Number
Student Disabled

Is there a child of the deceased not yet born?
Yes

When born, send birth certificate for child to OPM

No

Complete items 3b-3d below

Yes

3a. Do you (the applicant) have responsibility for all the children in Section E.1?
No
3b. Name and address of person having responsibility for child

3c. Name(s) of children

3d. Custodian's Relationship to
child
Legal guardian
Other

Specify

Legal guardian
Other

Specify

Legal guardian
Other

Page 2 of 4

Specify

Standard Form 2800
Revised June 2018

Section F - Information About Other Heirs
List other relatives who can inherit from the deceased as explained in the instructions. Do the best you can without delaying your application.
1.

Full name of relative

2.

Complete address

3.

Relationship to deceased

4.

Social Security
Number if known

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?

3.

If an executor, administrator or other official has not been court appointed, will one be appointed?

No

Go to item 3 below

2.

Full name and address of person appointed

Yes
Yes

No

Section H - Active Military Service (Complete ONLY if you are the surviving spouse or former spouse)
Complete if deceased was an 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 all items below and attach a
copy of the discharge certificate or other certificate of active military service (if available).
1b. Dates of active duty

1a. Branch of service
From

To

Complete if deceased was an employee at time of death. Also, complete and attach Standard Form 2800A which can be obtained from the deceased person's
employing agency.
2. If any of the above listed service was performed after 12/31/56, was a deposit
made to the Retirement Fund for the service?
Yes
No
Don't know
All spouses and former spouses complete 3a-3c.
3a. Was the deceased receiving military retired pay at the time of death?
3b. Did the deceased ever waive military retired pay?
3c. Are you eligible for military survivor benefits? (Attach verification
of your eligibility/ineligibility for such benefits.)

Yes

No

Don't know

Yes

No

Don't know

Yes

No

Section I - Payment Instructions
1.

Federal benefits payments will be made electronically by Direct Deposit into a savings or checking account or by a Direct Express debit card provided by the Department
of the Treasury. See SF 2800-1 for additional information. This does not apply to you if your permanent payment address is outside the United States in a country not
accessible via Direct Deposit. Please select one of the following:
Please send my annuity payments to my checking or savings account. (Go to item 2 on page 4.)
Please send my annuity payments to my Direct Express debit card. (Go to Section J.)
My permanent payment address is outside the United States in a country not accessible via Direct Deposit/Direct Express. (Go to Section J.)

Page 3 of 4

Standard Form 2800
Revised June 2018

Section I - Payment Instructions (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)?

Yes

No

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?

Yes

No

4.

5.

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.)
What kind of account is this?
6. Account number

7.

Checking
Name and address of your financial institution

8.

Telephone number of your financial institution (including area code)

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.

3.

Signature of applicant named in Section B. (Sign in ink; do not print.)

2.

Daytime telephone number

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)

(
5.

4.

Date (mm/dd/yyyy)

)

Email address

Mailing address

Note: We cannot process your application if you do not complete all of Section J.

Section K - Applicant's Checklist
Attach copies of the following documents to expedite the processing of your application.
Document Title

Attached

Remarks
Yes

Death certificate

Required in all cases.

Marriage certificate
or proof

Required if you were spouse of deceased at time of death (if married more than once,
provide copies of all certificates). Affidavits or other proofs of common law marriage
are required.
Recommended for all children for whom you are applying for benefits.

Child(ren)'s birth
certificate(s)
Court papers
appointing
executor/administrator
Court papers
appointing guardian or
other fiduciary

Required if you are applying as executor or administrator of deceased person's estate.

DD 214s or other
military discharge
certificates

Provide if you are applying as surviving spouse or former spouse and the deceased was
an employee at time of death. Failure to attach the information may delay the
processing of your claim.

Court order of
divorce/annulment

Required from former spouse if not already on record at OPM.
Needed from other applicants if available.

No

N/A

Comments

Required for minor or disabled children who have a court-appointed fiduciary.
Required for any incompetent applicant who has a fiduciary.

Page 4 of 4

Standard Form 2800
Revised June 2018