RI25-037_2018_03_MarkUp

United States
Office of Personnel Management
Retirement Operations Center
Attn: Survivor Claims
P.O. Box 45
Boyers, PA 16017

Form Approved:
OMB No. 3206-0206

Evidence to Prove Dependency of a Child
To establish eligibility for a child to receive survivor benefits, the law requires us to obtain proof that the child was financially
dependent on the deceased Federal employee or annuitant. Please read the instructions and submit the evidence for our
consideration. We can take no further action on your claim until we receive the required evidence.
A.

Did a court order the deceased to provide support for the child? If not, skip to item B below. If so, provide us a certified
copy of the court order; no other documents are needed to prove dependency.

B.

Did the child live with the deceased in a regular parent-child relationship at the time of the employee's or annuitant's death?
(If not, skip to item 2 below.)
1.

2.

If so, you and at least two other people who are not related to you or the deceased must submit separate affidavits for
each child to the address shown on the top of this form. All affidavits must be sworn to or affirmed before a notary
public or other officer who is authorized to administer oaths and must show:
a.

The name and address of the person making the statement;

b.

How the person is in a position to know the facts;

c.

That the child lived with the deceased in a regular parent-child relationship;

d.

The length of time the parent-child relationship existed; and

e.

That the deceased exercised parental authority, responsibility, and control over the child.

If the child did not live with the deceased in a regular parent-child relationship, you must show that the deceased made
regular and substantial contributions toward the child's support. To prove this, provide one or more of the following:
a.

Evidence of eligibility as a dependent child for benefits under other state and Federal programs.

b.

Proof of inclusion of the child as a dependent on the deceased's income tax returns for the year immediately prior
to death.

c.

Canceled checks, money orders, or receipts of periodic payments from the deceased for the child.

d.

Evidence of goods or services which show the deceased made regular contributions of considerable value to the
child's support.

e.

Proof of coverage of the child as a family member under the deceased's health benefits enrollment.

f.

Other proof of a nature similar to the above that demonstrates support of the child by the deceased.

Warning: All evidence is subject to verification by Federal investigators. Any intentionally false statement, concealment of a
material fact, or willful misrepresentation related to this claim is punishable by a fine of not more than $10,000 or imprisonment
of not more than 5 years, or both (18 U.S.C. 1001).
Public Burden Statement
We estimate this form takes an average 60 minutes per response to complete, including the time for reviewing instructions, gathering the required data, and
reviewing the completed package. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion
time, to the Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0206), Washington, DC 20415-0001. The OMB Number
3206-0206 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Thank you for your cooperation.
Retirement Services

Previous editions are usable

RI 25-37
Revised March 2018