Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death

Application for Death Benefits (FERS)/Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0172 can be found here:

Documents and Forms

Document Name Document Type
Form Standard Form 3104 Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form and Instruction
Standard Form 3104 Application for Death Benefits: FERS SF3104_2019_11.pdf www.opm.gov Form and Instruction
Standard Form 3104 Application for Death Benefits (FERS) SF3104_2019_11_MarkUp.pdf www.opm.gov Form and Instruction
Standard Form 3104 Documentation and Elections in Support of Application fo SF3104B_2019_11.pdf www.opm.gov Form and Instruction
Standard Form 3104 Documentation and Elections in Support of Application fo SF3104B_2019_11_MarkUp.pdf www.opm.gov Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 843

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Standard Form 3104	Application for Death Benefits: FERS	SF3104_2019_11.pdf	www.opm.gov	Yes	No	Fillable Printable
Form and Instruction	Standard Form 3104 (Highlight w/Changes)	Application for Death Benefits (FERS)	SF3104_2019_11_MarkUp.pdf	www.opm.gov	Yes	No	Fillable Printable
Form and Instruction	Standard Form 3104B	Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)	SF3104B_2019_11.pdf	www.opm.gov	Yes	No	Fillable Printable
Form and Instruction	Standard Form 3104B (Highlight w/Changes)	Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)	SF3104B_2019_11_MarkUp.pdf	www.opm.gov	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title: OPM/Central-1	FR Citation: 73 FR 15013

Number of Respondents: 16,751	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,751	0	16,751
Annual IC Time Burden (Hours)	16,751	0	16,751
Annual IC Cost Burden (Dollars)	225,066	225,066	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.