Public Safety Officers' Death Benefits Application

Section/Heading	Subheading	Modal?	Question	Field Type	Answer Choices (If applicable)	Required/Not Required	Instructional Text
Consent to Release Information and Assistance with your PSOB Application							The Public Safety Officers’ Benefits (PSOB) Office collaborates with various PSOB National Stakeholders, including the Concerns of Police Survivors, Inc. (C.O.P.S.) and National Fallen Firefighters Foundation (NFFF), to provide information and support to survivors and surviving agencies of America’s fallen and catastrophically injured Public Safety Officers. With funding from the Bureau of Justice Assistance, C.O.P.S. and NFFF provide a wide range of peer support and counseling services to survivors, as well as assistance with filing a PSOB application. By completing the consent to release below, you authorize the PSOB Office to release your name and contact information to C.O.P.S., NFFF, or any other organization you specify to contact you for assistance with your application.
			Pursuant to the Privacy Act (5 U.S.C. § 552a(b)), I consent to the release of my name and contact information to: Concerns of Police Survivors, Inc. (https://www.nationalcops.org).	Radio	Yes/No	Required
			Pursuant to the Privacy Act (5 U.S.C. § 552a(b)), I consent to the release of my name and contact information to: National Fallen Firefighters Foundation https://www.firehero.org).	Radio	Yes/No	Required
			Other Organization (please specify)	Text Box	NA	Not Required
In which capacity are you filing this application?
			Applicant Type	Radio	Applicant/Authorized Representative	Required
What type of Authorized Representative are you?			Authorized Representative Type	Radio	Attorney/Other	Required
			If "other" selected, describe the relationship to the Applicant:	Text Box	NA	Required (if "other" is chosen)
Enter the Public Safety Officer's information.
			Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Public Safety Officer First Name	Text Box	NA	Required
			Public Safety Officer Middle Name	Text Box	NA	Not Required
			Public Safety Officer Last Name	Text Box	NA	Required
			Public Safety Officer Suffix	Text Box	NA	Not Required
			Public Safety Officer Job Title	Text Box	NA	Required
			Public Safety Officer Employing Agency	Text Box	NA	Not Required
			Public Safety Officer Social Security Number (Enter in this format: 555-55-5555)	Text Box	NA	Required
			Public Safety Officer Date of Birth	Text Box/Date Picker	NA	Required
			Public Safety Officer Date of Injury	Text Box/Date Picker	NA	Required
			Public Safety Officer Date of Death	Text Box/Date Picker	NA	Required
			What is the Applicant's relationship to the Public Safety Officer?	Radio	Surviving Spouse Surviving Spouse with Minor Child(ren) Minor Child(ren) PSOB Beneficiary Designee(s) on file with the Employing Agency at the time of Officer’s death Life Insurance Beneficiary(ies) on file with the Employing Agency at the time of Officer’s death Surviving Parent Adult Child(ren) Other	Required
Name of Minor Child's Parent or Legal Guardian			Name of Minor Child's Parent or Legal Guardian	Text Box	NA	Required (if minor child is chosen in the "What is the Applicant's relationship to PSO" question.
Verification of capacity in which the Applicant is filing.
			I verify that I have read and understand this information.	Check Box	NA	Required	1) Officer’s Surviving Spouse and Minor Child(ren) A Minor Child is defined as a Child of the Officer who was less than 18 years of age at the time of the Officer’s fatal injury, or a Child who was between the ages of 19-22 at the time of the Officer’s fatal injury in addition to being a full-time student at the time of the Officer’s fatal injury. If the Officer has a Surviving Spouse and no Minor Children, the spouse receives 100% of the benefit; if the Officer has a Surviving Spouse and a Child or Children, the Spouse receives 50% of the benefit, while the Children receive the remaining 50% of the benefit in equal shares. If the Officer has no Surviving Spouse or Minor Children, the next eligible beneficiary on the benefits hierarchy would be the: 2) PSOB Designee on file with the Agency at the time of the Officer’s death The PSOB Designee on file with the Agency at the time of the Officer’s death is the beneficiary for PSOB benefits that was specifically designated by the Officer prior to his or her fatal injury, if such a designation was made, and which was on file with the Agency at the time of the Officer’s fatal injury. If there was such a designation, a copy of the written designation that was on file with the Officer’s Agency at the time of his or her fatal injury must be provided. If the Officer has no Surviving Spouse or Minor Children, and had no PSOB Designee on file with the Agency at the time of his or her fatal injury, the next eligible beneficiary on the benefits hierarchy would be the: 3) Life Insurance Designee on file with the Agency at the time of the Officer’s death The Life Insurance Designee on file with the Agency at the time of the Officer’s death is the Life Insurance Beneficiary that was specifically designated by the Officer prior to his or her fatal injury, if such a designation was made, and which was the most recently executed designation on file with the Agency at the time of the Officer’s fatal injury. If there was such a designation, a copy of the written designation and policy that was on file with the Officer’s agency at the time of his or her fatal injury must be provided. If the Officer has no Surviving Spouse or Minor Children, and had no PSOB Designee on file with the Agency at the time of his or her fatal injury, as well as no Life Insurance Designee on file with the Agency at the time of his or her fatal injury, the next eligible beneficiary on the benefits hierarchy would be the: 4) Officer’s Surviving Parents If the Officer has one Surviving Parent, the Surviving Parent receives 100% of the benefit; if the Officer has more than one Surviving Parent, each Parent receives the benefit in equal shares. If the Officer has no Surviving Spouse or Minor Children, and had no PSOB Designee on file with the Agency at the time of his or her fatal injury, as well as no Life Insurance Designee on file with the Agency at the time of his or her fatal injury, and also had no Surviving Parents, the next and final eligible beneficiary on the benefits hierarchy would be the: 5) Officer’s Surviving Adult Child(ren) An Adult Child is defined as a Child of the Officer that does not qualify as a Minor Child due to age. 6) Other None of the above situations describe the relationship to the Public Safety Officer.
What was the Public Safety Officer's marital status at the time of death?
			Public Safety Officer's Marital Status	Radio	Never Married, Married, Divorced or Annulled, Widowed	Required
Enter information about the Public Safety Officer's Surviving Spouse.
			Spouse’s Total Number of Marriages (include the marriage to the Public Safety Officer)	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required
		"Add Surviving Spouse" modal					Enter information about the Public Safety Officer's surviving spouse.
	Add Surviving Spouse of Public Safety Officer		Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other (please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Address Line 1	Text Box	NA	Required
			Address Line 2	Text Box	NA	Not Required
			City	Text Box	NA	Required
			State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Zip/Postal Code	Text Box	NA	Required
			Country	Text Box	NA	Not Required
			Phone Number	Text Box	NA	Required
			Alternate Phone Number	Text Box	NA	Not Required
			Date Marriage Began	Text Box/Date Picker	NA	Not Required
			Email Address	Text Box	NA	Required
			Are you authorized to represent this individual?	Dropdown	Yes, No, Not Specified	Required
		"Add Previous Marriage" modal					Add information about all of the Surviving Spouse's previous marriages (if applicable):
	Add Previous Marriage of Surviving Spouse		Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Date Marriage Ended	Text Box/Date Picker	NA	Required
			How did the previous marriage end?	Dropdown	Death, Divorce/Annulment, Unknown	Required
			Did the Public Safety Officer have previous marriages?	Radio	Yes/No	Required
Public Safety Officer's Previous Marriages			How many times was the Public Safety Officer previously married? (Excluding the surviving spouse)	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required
		"Add Officer's Previous Marriage" modal					Add information about all of the Officer's previous marriages.
Add Previous Marriage of Public Safety Officer			Prefix	Dropdown	Mr., Mrs., Ms. Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Previous Spouse First Name	Text Box	NA	Required
			Previous Spouse Middle Name	Text Box	NA	Not Required
			Previous Spouse Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Date Marriage Began	Text Box/Date Picker	NA	Not Required
			Date Marriage Ended	Text Box/Date Picker	NA	Required
			How did the previous marriage end?	Dropdown	Death, Divorce/Annulment, Unknown	Required
			Are you authorized to represent this individual?	Dropdown	Yes, No, Not Specified	Required
			Did the Public Safety Officer have any Children at the time of fatal injury? *	Radio	Yes/No	Required
Public Safety Officer's Children			How many Children did the Public Safety Officer have?	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required
		"Add Child" Modal					Add information about all of the Officer's children.
			Child Type	Dropdown	Biological, Legally Adopted Child, Stepchild, Other)	Required
			If other, please briefly describe	Text Box	NA	Only required if "other" chosen in previous question.
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Address Line 1	Text Box	NA	Required
			Address Line 2	Text Box	NA	Not Required
			City	Text Box	NA	Required
			State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Zip/Postal Code	Text Box	NA	Required
			Country	Text Box	NA	Not Required
			Phone Number	Text Box	NA	Required
			Alternate Phone Number	Text Box	NA	Not Required
			Email Address	Text Box	NA	Not Required
			Date of Birth	Text Box/Date Picker	NA	Required
			Was the Child a full-time student between the ages of 19 and 22 and enrolled as a full-time student at the time of the Officer's fatal injury?	Radio	Yes/No	Required
			Is the Applicant the Parent or Legal Guardian of this Child?	Radio	Yes/No	Required
			If not, please provide the name of the Parent or Legal Guardian.	Text Box	NA	Only required if "no" chosen in previous question.
			Is the Child incapable of self-support due to a physical or mental disability?	Radio	Yes/No	Required
			Are you authorized to represent this individual?	Dropdown	Yes, No, Not Specified	Required
			Did the Public Safety Officer have a Public Safety Officer Benefits' (PSOB) Designee(s) on file with the Employing Agency at the time of death?	Radio	Yes/No	Required
Enter information about the Public Safety Officers' Benefits (PSOB) Designee(s)			Number of Designees	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required	The PSOB Designee on file with the Agency is the individual who was to receive PSOB benefits according to the designation on file with the agency at the time of the Officer’s death.
		Add PSOB Designee					Add information about all PSOB Designee(s) on file with the Employing Agency.
			Prefix	Dropdown	Mr. Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Only required if other chosen in previous question
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Address Line 1	Text Box	NA	Required
			Address Line 2	Text Box	NA	Not Required
			City	Text Box	NA	Required
			State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Only required if other chosen in previous question
			Zip/Postal Code	Text Box	NA	Required
			Country	Text Box	NA	Not Required
			Phone Number	Text Box	NA	Required
			Alternate Phone Number	Text Box	NA	Not Required
			Email Address	Text Box	NA	Required
			Are you authorized to represent this individual	Dropdown	Yes, No, Not Specified	Required
			Did the Public Safety Officer have a Life Insurance Beneficiary(ies) on file with the Employing Agency at the time of death?	Radio	Yes/No	Required
Enter information about the Life Insurance Beneficiary(ies).			Total number of Life Insurance Designees	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required	The Life Insurance Designee on file with the Agency is the individual who was named in the Officer's life insurance policy, according to the designation on file with the Agency at the time of the Officer’s death.
		Add Life Insurance Beneficiary					Add information about all Life Insurance Beneficiary(ies) on file with the Employing Agency.
			Prefix	Dropdown	Mr. Mrs., Ms. Miss, Dr., Other(please describe)
			Describe "other" here	Text Box	NA
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Address Line 1	Text Box	NA	Required
			Address Line 2	Text Box	NA	Not Required
			City	Text Box	NA	Required
			State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Only required if other chosen in previous question
			Zip/Postal Code	Text Box	NA	Required
			Country	Text Box	NA	Not Required
			Phone Number	Text Box	NA	Required
			Alternate Phone Number	Text Box	NA	Not Required
			Email Address	Text Box	NA	Required
			Are you authorized to represent this individual	Dropdown	Yes, No, Not Specified	Required
			Did the Public Safety Officer have Surviving Parents?	Radio	Yes/No	Required
Enter information about the Officer's Parent(s) or Legal Guardian(s)
			Number of Parents/Legal Guardians	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required	Add information about the Officer's Parent(s) or Legal Guardian(s).
		Add Parent (modal)
			Prefix	Dropdown	Mr. Mrs., Ms. Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Not Required
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Address Line 1	Text Box	NA	Required
			Address Line 2	Text Box	NA	Not Required
			City	Text Box	NA	Required
			State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Only required if other chosen in previous question
			Zip/Postal Code	Text Box	NA	Required
			Country	Text Box	NA	Not Required
			Phone Number	Text Box	NA	Required
			Alternate Phone Number	Text Box	NA	Not Required
			Email Address	Text Box	NA	Required
			Is this individual still living?	Dropdown	Yes/No	Required
			Are you authorized to represent this individual	Dropdown	Yes, No, Not Specified	Required
Public Safety Officer Surviving Adult Children
			Did the Public Safety Officer have Surviving Adult Children?	Radio	Yes/No	Required
Enter information about the Surviving Adult Children			Number of Adult Children	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required	Add information about any of the Officer’s Adult Children that you did not enter previously.
		Add Adult Child (modal)
			Child Type	Biological Child, Legally Adopted Child, Stepchild, Other		Required
			If other, please briefly describe	Text Box		Only required if other chosen in previous answer
			Prefix	Dropdown	Mr. Mrs., Ms. Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box	NA	Not Required
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Address Line 1	Text Box	NA	Required
			Address Line 2	Text Box	NA	Not Required
			City	Text Box	NA	Required
			State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Only required if other chosen in previous question
			Zip/Postal Code	Text Box	NA	Required
			Country	Text Box	NA	Not Required
			Phone Number	Text Box	NA	Required
			Alternate Phone Number	Text Box	NA	Not Required
			Email Address	Text Box	NA	Required
			Date of Birth	Text Box/Date Picker	NA	Required
			Are you authorized to represent this individual	Dropdown	Yes, No, Not Specified	Required
Other Beneficiary							You have indicated that your relationship to the Public Safety Officer does not fall into one of the previous categories. Please use the section below to describe your relationship to the Public Safety Officer as well as your contact information.
			Number of Other Beneficiaries	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required
		"Add Other" Modal
			Relationship to the Public Safety Officer	Text Box	NA	Required
			Prefix	Drop Down	Mr. Mrs., Ms. Miss, Dr., Other(please describe)
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Address Line 1	Text Box	NA	Required
			Address Line 2	Text Box	NA	Not Required
			City	Text Box	NA	Required
			State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Required (if "other" is chosen)
			Zip/Postal Code	Text Box	NA	Required
			Country	Text Box	NA	Not Required
			Phone Number	Text Box	NA	Required
			Alternate Phone Number	Text Box	NA	Not Required
			Email Address	Text Box	NA	Required
			Are you authorized to represent this individual	Dropdown	Yes, No, Not Specified	Not Required
Other Benefits
			Has a claim for benefits been filed under any of the following: (Check all that apply)	Checkbox	State Line of Duty Death Benefits Workers' Compensation Federal Employees Compensation Act D.C. Retirement and Disability Act of September 1, 1916 September 11th Victim Compensation Fund Other (please describe) None of the Above (please describe)	Required
			Describe "other" or "none of the above" here:	Textbox	NA	Only required if other or none of the above was chosen in the previous question
			Has a final determination been issued for any of the following: (Check all that apply)	Checkbox	State Line of Duty Death Benefits Workers' Compensation Federal Employees Compensation Act D.C. Retirement and Disability Act of September 1, 1916 September 11th Victim Compensation Fund Other (please describe) None of the Above (please describe)	Required
			Describe "other" or "none of the above" here:	Textbox	NA	Only required if other or none of the above was chosen in the previous question
APPLICATION PREVIEW	Please Review and Confirm						The following is a summary of the information you have entered. Please review and make any necessary changes to this page before submitting your application.
Required Documents							Based on your responses, a customized checklist has been generated. The following required documents must be uploaded for the application to be considered complete. If you have any questions, please contact the PSOB Customer Resource Center at 1-888-744-6513 or [email protected].
			Association	Static Text Box	NA	Auto filled
			Document Type	Static Text Box	NA	Auto filled
			Date Uploaded	Static Text Box	NA	Auto filled
			Instructions	Static Text Box	NA	Auto filled	All doc instructions are located in the "Required Documents and Instructions" tab
			Review Status	Static Text Box	NA	Auto filled
			Add document clarifying notes if necessary.	Text Box	NA	Not Required
			Missing Document Justification	Text Box	NA	Required only if a required document is not uploaded
		Click here to Add Other Documentation. (Modal)
Missing Documents							Your application is missing one or more required documents needed to successfully submit your application. Please go to the previous screen to review the list of required documents, to upload all required documents or to provide an explanation of why a document is missing.
CERTIFICATION OF APPLICATION							The information provided will be used by the Department of Justice to determine eligibility of an Applicant/Claimant for PSOB Program benefits. To verify eligibility for benefits, the information provided is subject to investigation and may be disclosed to federal, state, tribal, and local agencies to verify eligibility for benefits. If the Department of Justice receives adverse information regarding an Applicant’s or Claimant’s eligibility, an information of record may be disclosed as necessary to affected persons and federal, state, tribal, and local agencies, including those persons or agencies challenging eligibility. I certify that all of the information provided is correct and complete to the best of my knowledge. I know of no facts or circumstances that would render the person identified here as ineligible for the benefit. I understand that knowingly and willfully making a false or incomplete statement or failing to fully disclose pertinent information concerning this claim may be grounds for non-payment of benefits or for prosecution for a false statement under 18 U.S.C. § 1001. Checking the box below asserts that you have read and understand this Certification of Application, and will be treated as an electronic signature by or on behalf of the Applicant. If you are ready to submit your application, click the “Next/Save” button. If you need to make changes to your application, click the “Previous” button.
			Certification of Application	Checkbox	NA	Required
FINAL REVIEW FORM	Please Review and Confirm						This final review form serves as the version of the application you are about to submit. If you wish to make edits, return to the editable preview screen to do so.
Application Part A Successfully Submitted							A PSOB Death Benefits Application consists of two parts, Part A and Part B. Part A is completed by the Officer’s beneficiary or Authorized Representative, Part B is completed by the Employing Agency. Parts A and B, and all required supporting documents must be provided before the application can be considered complete. A Customer Resource Specialist will review the application. If all required documents are provided, the application will be assigned a claim number and will move to the next stage of review. If the contact information you initially provided changes, please log into the PSOB portal to update your contact details.