Public Safety Officers' Death Benefits Application

Application Type	Triggering Question	Document Type	Association	Instructions
Death Part A	In which capacity are you filing this application? If Authorized Representative:	Letter of Representation	<Authorized Representative>	Provide a letter of representation stating that the authorized representative has the authority to act on the claimant’s behalf.
	Public Safety Officer Date of Death	Death Certificate	<Public Safety Officer>	The Public Safety Officer's Death Certificate is requested in order to confirm the date, time and cause of the fallen Officer's death. The death certificate should be signed by a physician, list the cause of death, the date and time, and also the place where the death occurred.
	What was the Public Safety Officer’s marital status at the time of death? If Married:	Marriage Certificate or Evidence of Marriage	<Public Safety Officer>	The marriage certificate is used to verify the marital relationship between the surviving spouse and Public Safety Officer.
	How did the previous marriage end? If Divorced or Annulled:	Divorce or Annulment Decree	<Surviving Spouse's Previous Spouse>	If the surviving spouse of the Public Safety Officer was previously married, provide the divorce or annulment decree for that and each previous marriage. A divorce or annulment decree is a legal document, generally provided by a judge, which serves as evidence of the dissolution of the marriage.
	How did the previous marriage end? If Death:	Death Certificate	<Surviving Spouse's Previous Spouse>	If the surviving spouse of the Public Safety Officer was previously married and the marriage ended in death, provide a death certificate for the surviving spouse's previous marriage. The death certificate should be signed by a physician, list the cause of death, the date and time, and also the place where the death occurred.
	How did the previous marriage end? If Divorced or Annulled:	Divorce or Annulment Decree	<Public Safety Officer’s Previous Spouse>	If the Public Safety Officer was previously married, provide the divorce or annulment decree for that and each previous marriage. A divorce or annulment decree is a legal document, generally provided by a judge, which serves as evidence of the dissolution of the marriage.
	How did the previous marriage end? If Death:	Death Certificate	<Public Safety Officer's <Previous Spouse>	If the Public Safety Officer was previously married, and the marriage ended in death, provide a death certificate for the previous marriage. The death certificate should be signed by a physician, list the cause of death, the date and time, and also the place where the death occurred.
	Child Type. If Biological…	Birth Certificate	<Child>	Provide birth certificates for all of the Public Safety Officer's surviving children (regardless of child-type, age, or dependency).
	Child Type. If Adopted…	Adoption Document or Birth Certificate	<Child>	Provide evidence of adoption in order to certify the relationship between the Public Safety Officer and his or her adopted child(ren).
	Child Type. If Stepchild:	Custody Order or Agreement	<Child>	The child custody order or agreement is required by the PSOB Office in order to confirm the custodial arrangement of the step-child(ren) listed in the benefits claim. The child custody order is an official document provided by a judge or magistrate, which describes the legal or physical custody of a child, while a child custody agreement is an agreement signed by both parties.
	Child Type. If Stepchild:	Birth Certificate	<Child>	Provide birth certificates for all of the Public Safety Officer's surviving children (regardless of child-type, age, or dependency).
	Child Type. If Other:	Evidence of Parent-Child Relationship with Public Safety Officer	<Child>	A parent-child relationship is defined as a relationship between a Public Safety Officer and another individual, in which the officer has the role of parent (other than biological or legally-adoptive). There are several documents that PSOB accepts as evidence of a parent-child relationship. Examples of accepted documents may include: 1) statements from school administrators, church clergy, or social workers that describe the relationship between the Public Safety Officer and the child. 2) Tax documentation showing that the child was claimed as a dependent by the Public Safety Officer. 3) Statements confirming that the child in question received more than half of their support from the Public Safety Officer, or which shows that the primary residence of the child was the same as the Public Safety Officer.
	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? If yes:	Evidence of Full-Time Student Status	<Child>	For each child who is between the ages of 19 and 22, and a full-time student at the time of the Public Safety Officer's death, provide an enrollment verification document from the school confirming the child's status as a full-time student at the time of the Public Safety Officers' death.
	Is the child incapable of self-support due to physical or mental disability? If yes:	Evidence of Child's Disability	<Child>	Provide evidence confirming the child's disability in order to certify that the child is incapable of self-support due to a physical or mental disability.
	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? If Yes:	PSOB Designation Form (on file with the agency)	<PSOB Designee>	A PSOB Benefits' Designee is a beneficiary who is designated in official documents on file with the Public Safety Officer’s employing agency, as the intended recipient of any PSOB Federal Benefits.
	Did the Public Safety Officer have a Life Insurance Designee(s) on file with the Employing Agency at the time of death? If Yes:	Life Insurance Policy and Designation of Beneficiary (on file with the agency)	<Life Insurance Designee>	A Life Insurance Beneficiary on file with the agency refers to the beneficiary who is named in the Public Safety Officer's most recent life insurance policy (on file with their Public Safety Agency) at the time of the Public Safety Officer's death. The document(s) provided should be the most recently executed copies on file with the agency.
	Did the Public Safety Officer have Surviving Parents? If Yes:	Officer’s Birth Certificate or Adoption Document	<Public Safety Officer>	Provide a birth certificate or evidence of adoption in order to certify the relationship between the Public Safety Officer and his or her surviving parent(s).
	Is this individual still living?	Death Certificate	<Parent>	Provide a death certificate if the parent(s) of the Public Safety Officer are deceased. The death certificate should be signed by a physician, list the cause of death, the date and time, and also the place where the death occurred.
	Did the Public Safety Officer have Surviving Adult Children? If Yes:	Birth Certificate	<Adult Child>	Provide birth certificates for all of the Public Safety Officer's surviving children (regardless of child-type, age, or dependency).
	Has a final determination been issued for any of the following? If State Line of Duty Death Benefits:	Other Benefits	<State Line of Duty Death Benefits Decision>	The State Line of Duty Death Benefit final decision is an evidentiary document certifying that a decision has been rendered on a State Line of Duty Death claim.
	Has a final determination been issued for any of the following? If Workers’ Compensation:	Other Benefits	<Workers’ Compensation Decision>	The Workers’ Compensation final decision is an evidentiary document certifying that a decision has been rendered on a Workers’ Compensation claim.
	Has a final determination been issued for any of the following? If Federal Employees' Compensation Act:	Other Benefits	<Federal Employees' Compensation Act Decision>	The Federal Employees' Compensation Act (FECA) final decision is an evidentiary document certifying that a decision has been rendered on a FECA claim.
	Has a final determination been issued for any of the following? If DC Retirement and Disability Act:	Other Benefits	<DC Retirement and Disability Act Decision>	The DC Retirement and Disability Act final decision is an evidentiary document certifying that a decision has been rendered on a DC Retirement and Disability claim.
	Has a final determination been issued for any of the following? If September 11th Victim Compensation Fund:	Other Benefits	<September 11th Victim Compensation Fund Decision>	The September 11th Victim Compensation Fund (VCF) final decision is an evidentiary document certifying that a decision has been rendered on a September 11th VCF claim.