Standard Form 3104 Application for Death Benefits: FERS

Application for Death Benefits

OMB Approval 3206-0172

Federal Employees Retirement System
This application is for use by persons applying for benefits which may be payable under the Federal Employees Retirement System (FERS)
because of the death of an employee, former employee, or retiree who was covered by FERS at the time of his/her death or separation from
Federal service. You can reference the informational pamphlet entitled, Applying for Death Benefits Under the Federal Employees Retirement
System, SF 3114 online at www.opm.gov/retirement-services/publications-forms/. You can either write to the Office of Personnel Management
at OPM, FERS, P.O. Box 45, Boyers, PA 16017-0045 or call OPM's Retirement Information Office at 1-888-767-6738.
If the deceased was an employee at the time of death, send your completed application, with any requested 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 OPM,
FERS, P.O. Box 45, Boyers, PA 16017-0045.
If your address changes before you receive your claim number, write to OPM, giving 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, please refer to it.
Section C - Information About the Deceased Person's
Spouse
1. Attach a copy of your marriage certificate.

Instructions For Completing Application
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 (?).
The following additional information should help you to answer
those questions on the application which are not entirely selfexplanatory.

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 which clearly show: (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 being husband and wife
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.

Section A - Information About the Deceased
6.
7.

8.

If deceased had ever applied for or received retirement
benefits, show the CSA number (retirement claim number).
Recurring payments from the Office of Workers'
Compensation Programs (OWCP), U.S. Department of Labor
and FERS survivor annuity benefits and/or the FERS Basic
Employee Death Benefit usually are not payable for the same
period of time. If the deceased ever applied for or received
benefits from OWCP based on an illness or injury resulting
from a condition of employment, indicate here. The OWCP
claim number appears on correspondence from OWCP.
See the pamphlet entitled, Applying for Death Benefits Under
the Federal Employees Retirement System, SF 3114 to help
you determine which block to check.

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

10. If the deceased had no former marriage(s), write "none."
Attach copies of death certificates, divorce decrees from
former marriage(s) or annulment(s). If you are the spouse of
the deceased and were married to the deceased before, be sure
to show the date your prior marriage(s) ended.
Section B - Information About the Applicant
5.

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.)

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

2.

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If you married the deceased more than once, give dates that
each marriage began and ended.

(Instructions) Standard Form 3104
Revised November 2019
Previous editions are not usable.

Section E - Information About the Deceased Person's
Dependent Children
1a. 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:
►

►

►

Section F - Information About Other Heirs
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);

was under age 18 at the time of the deceased person's
death, including any:
1. adopted child, and/or
2.

stepchild, and/or

3.

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

4.

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, but who became mentally and/or
physically disabled before age 18 and who, because
of the disability, is incapable of self-support. Attach a
copy of the Social Security Administration's
determination of disability (prior to age 18) for
disabled child(ren) over age 18.

►

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 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 relatives who can inherit
from the deceased.

Section G - Information About the Deceased Person's
Estate
1. If someone was named as executor or administrator in the
deceased person's will, but hasn't been appointed by a court,
check "No." If you have been appointed by a court, attach a
copy of the court appointment.

is between ages 18 and 22 and who is unmarried and a
full-time student in school.

1b. Attach a copy of the birth certificate for each child for whom
you are applying.

Section H - Active Military Service

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.

You do not need to complete parts 1 and 2 of this section if the
deceased was retired at the time of death, since the Office of
Personnel Management (OPM) already has this information.

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.
2. The mother of the unborn child, the legal guardian or the
person responsible for the child should send us the birth
certificate, when available.

1.

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.
4. You must apply for benefits from the Social Security
Administration (SSA) for minor or disabled children of the
deceased. Federal Employees Retirement System (FERS)
benefits to children will not be paid until we have received
verification of their entitlement to (and amount of) or lack of
entitlement to SSA benefits. You should submit a copy of
SSA's notice of award or denial with this application, if
available. If it is not submitted, we will obtain the information
from SSA, however, this may delay the processing of your
claim.

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 services 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. However, full-time National Guard duty (as defined in
Section 101(d) of Title 10) 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 the deceased was a
retiree, OPM already has information about his/her military
service.
If you have a copy of the deceased person's DD 214's or other
discharge certificate(s) showing the dates of active duty and
the deceased was a former employee at the time of death, you
should attach it (them) to your application.

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(Instructions) Standard Form 3104
Revised November 2019

2.

3.

If you choose this option, your annuity payment will be
automatically deposited to the Direct Express card on the
payment date. To obtain a debit card, go to www.godirect.org or
call 1-800-333-1795. If your payments are not electronically
deposited to your account and you do not have a Direct Express
card, you must contact the Department of Treasury at
1-800-333-1795.

Persons who performed active military service after
December 31, 1956, must pay or have paid a deposit to
receive credit under the Federal Employees Retirement
System (FERS) 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 Documentation and Elections in
Support of Application for Death Benefits when Deceased was
an Employee at the Time of Death, Standard Form (SF)
3104B, which can be obtained from the agency where the
deceased was last employed. The deceased's agency can
provide you with more information regarding this deposit.
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.

You cannot receive your survivor annuity payments by direct
deposit or the Direct Express debit card program if your
permanent payment address is outside the United States in a
country where these programs are not available.
Section K - Applicant's Checklist
Use this section of the application to ensure that all required
supporting documentation is attached.
SF 3104A
If the deceased was a retiree at the time of death and you are
the surviving spouse, you should complete Survivor Supplement
(FERS), SF 3104A, which is attached to this application.
Instructions for completing SF 3104A are contained on the
form itself.

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 Chapter 1223, title 10,
U.S. Code (formerly Chapter 67, Title 10), no such reduction
is required. You should attach a copy of your award of
military survivor benefits verifying the award was based on
one of the above reasons.

SF 3104B
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 Documentation and Elections
in Support of Application for Death Benefits when Deceased
was an Employee at the Time of Death, SF 3104B, which can
be obtained from the deceased person's former employing agency.
Instructions for completing SF 3104B are contained on the
form itself.

Section I - Payment Instructions
Complete in all cases. The US Department of the Treasury pays
all Federal benefit payments electronically. Most Federal
payments are paid by Direct Deposit into a savings or checking
account at a financial institution. If you do not have a bank
account, or prefer not to have your survivor annuity payments
deposited directly to your bank account, you can choose a Direct
Express debit card.

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 Chapter 84, Title 5, U.S. Code. 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 you furnish will be used to identify records properly associated with your application for Federal benefits, to obtain
additional information if necessary, to determine and allow present or future benefits, and to maintain a uniquely identifiable claim file.
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 benefits. 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 determination or continuation of benefits under
this program, 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, it may result in a delay or prevent action on your application.
Public Burden Statement

We estimate this form takes an average of 60 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 (3206-0172), Washington, D.C. 20415-0001.
Completed application forms should not be sent to this address. The OMB Number 3206-0172, is currently valid. OPM may not collect this information,
and you are not required to respond, unless this number is displayed.

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(Instructions) Standard Form 3104
Revised November 2019

OMB Approval 3206-0172

Application for Death Benefits
Federal Employees Retirement System

Section A - Information About the Deceased
1.

Full name of the 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 Number

5. List any other names the deceased used (ex. 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 (OWCP), Department of Labor?

7b. OWCP claim number

No

Yes

Former
employee

Retiree (If you are the surviving spouse, complete
SF 3104A [attached])

►
8. What was the employment status of the deceased at the time of death? (see pamphlet entitled, Applying for Death Benefits Under the Federal Employees Retirement System,
SF 3114)

Employee
9.

►

Complete SF 3104B, which can be obtained from the
former employing agency of the deceased.

Name of the spouse of the deceased at the time of death (if not married at time of death write "none")
10a. Name of the spouses from all former marriages
of the deceased

10b. How did each marriage end?

10c. Date each marriage ended
(mm/dd/yyyy)

Death

Divorce/annulment

Death

Divorce/annulment

Section B - Information About the Applicant
1.

Your full name (last, first, middle)

4.

Are you a citizen of the United States of America?

5.

I am applying for benefits as (check all boxes that apply):

2.

Yes

3.

Social Security Number

No

Widow(er)
Designated beneficiary (attach copy of designation, if available)
Parent of decedent (Each parent should complete a separate
application. If one parent is deceased, attach a copy of the
death certificate.)

6.

Date of birth (mm/dd/yyyy)

Executor or administrator of estate (attach copy of court order)
Former spouse (complete Section D on page 2)
Child (or as guardian of minor or disabled child)
Other (specify):

Did you cash any check(s) issued to the deceased or did you withdraw funds paid by direct deposit from the deceased's savings or checking account after the date of death?

Yes

No

Section C - Information About the Spouse of the Deceased (Complete if you are the widow[er].)
1.

Marriage performed by

3.

Have you remarried after your spouse died?

Clergy/Justice of the Peace
Yes

2.

Date of marriage (mm/dd/yyyy)

Other (explain)
No

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

Yes, complete items 4b-4e below

4b.

Name of deceased former spouse

4c. Date of birth (mm/dd/yyyy)

4d.

Name of retirement system (e.g. Civil Service, Foreign Service)

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

If you will be receiving monthly payments, make sure you complete the payment instructions in Section I.

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

Page 1 of 4

Standard Form 3104
Revised November 2019

Section D - Information About the Former Spouse of the Deceased (Complete if you are a former spouse)
1a. Date of marriage to the deceased (mm/dd/yyyy)

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

2. Is there a court order awarding you any portion of the Federal Employees Retirement System (FERS) retirement or survivor benefits of the deceased?

Yes, on record at OPM

Yes, attached

No

3a. Are you paying for Federal Employees Health Benefits coverage to a former employing office?

No, go to item 4a

Yes, go to item 3b

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

4a. Have you married again since your marriage to the deceased?

4b. Date of first marriage after marriage to the deceased ended (mm/dd/yyyy)

No, go to item 5a

Yes, 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 A1??

No, go to Section E

Yes, complete items 5b-5e below

5b. Name of deceased former spouse (last, first, middle initial)

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

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

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

If you will be receiving monthly payments, make sure you complete the payment instructions in Section I.
Special Note: If you checked "Employee" in Section A.8, and your former spouse performed more than 18 months of creditable civilian Federal
service, and a court awards you all or a portion of the Basic Employee Death Benefit or a survivor annuity, contact the former employing
agency of the deceased in order to complete the necessary election forms in Standard Form 3104B.
Section E - Information About the Deceased Person's Dependent Children
1a. Are there any unmarried dependent children as defined in the instructions?

Yes, complete items 1b-1f below
1b. Name(s) of unmarried dependent children
(list in order of birth)

No, go to Section F
1c. Date of birth
(mm/dd/yyyy)

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

1e. Age 18
or over
Disabled

Student

1f. Child's Social
Security Number

2. Is there a child of the deceased not yet born?

Yes, when born, send birth certificate for child to OPM

No

3a. Do you (the applicant) have the responsibility for all the children in Section E1?

No, complete items 3b-3d below

Yes, go to item 4a

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 (specify)

Page 2 of 4

Standard Form 3104, Revised November 2019

4a. Has anyone applied for benefits from the Social Security Administration (SSA) for minor or disabled children of the deceased?

No, application required for payment of benefits

Yes

4b. Have you attached a copy of the SSA's Notice of Award of benefits, and/or denial of benefits, and/or disability determinations for each child?

No, not yet received (forward to OPM upon receipt)

Yes

Section F - Information About Other Heirs
List other relatives who can inherit from the deceased as explained in the instructions.
1. Full name of relative

2. Complete address

3. Relationship to deceased

4. Social Security Number (if known)

Section G - Information About the Estate of the Deceased
1.

Has an executor, administrator or other official been appointed by the court to settle 2. Full name and address of person appointed (street, city, state, ZIP code)
the estate of the deceased?

No, go to item 3 below

Yes, go to item 2

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

Yes

No

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

a. Branch of service

2.

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Complete if the deceased was an employee or former employee at time of death. If any of the above listed service was performed after 12/31/56, was a deposit to the
Retirement Fund made for the service?

Yes

Don't know

No. If the deceased was an employee at the time of death, complete and attach Standard Form 3104B which
can be obtained from the former employing agency of the deceased.

3a. All surviving spouses and former spouses complete.
Was the deceased receiving military retired pay at the time of death?

Yes
Yes

3b. Did the deceased ever waive military retired pay?

No
No

3c. Are you eligible for military survivor benefits? (Attach verification of your eligibility/ineligibility for such benefits)

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 the instructions for Section I of this application and SF 3114 (Applying for Death Benefits Under the Federal Employees Retirement System) 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 survivor annuity payments directly to my checking account or savings account. (Go to item 2.)
Please send my survivor annuity payments directly 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 3104
Revised November 2019

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. 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.)
5. Checking or savings account number
7.

6. What kind of account is this?

Name and address of your financial institution

8. Telephone number of your financial institution (including are code)

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

2. Mailing address

3. Daytime telephone number (area code)

4. E-mail address

3a. Best time to call you

5. Date (mm/dd/yyyy)

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)

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

Requirement

Death certificate

Certified copy required in all cases

Marriage certificate

Required if you were the spouse of the deceased at time of death (if married more
than once, provide copies of all certificates)

Child(ren)'s birth certificate

Comments

Recommended for all children for whom you are applying for benefits

Social security award
determinations

Needed for all minor children and spouse if spouse is under 60 and is currently
eligible for mother, father or disability benefits from the Social Security
Administration (SSA), based on deceased person's service. Also needed for all
children who are unmarried and are age 18 or older, but who became mentally and/
or physically disabled before age 18 and who, because of disability, are incapable
of self-support. If not submitted, the Office of Personnel Management (OPM) will
obtain the information from SSA; however, this may delay the processing of your
claim.

Court papers appointing
executor/administrator

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

Court papers appointing
guardian for minor or
disabled child(ren)

Required if you are applying on behalf of minor or disabled children of the
deceased and guardian has been appointed by court.

DD 214's or other military
discharge certificates

Attached
Yes No N/A

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

Page 4 of 4

Standard Form 3104
Revised November 2019

OMB Approval 3206-0172

Survivor Supplement
Federal Employees Retirement System

Complete this form if the deceased was retired at the time of death.
Attach this form to the Application for Death Benefits, SF 3104, before forwarding it to the
Office of Personnel Management (OPM).
To be completed by surviving spouse if he/she is under age 60 and the deceased had at least 5 years of creditable civilian service.
Identifying Information
Full name of the deceased (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

CSA claim number

A survivor's supplement is an additional benefit to the basic survivor annuity death benefit that is equal to the lesser of:
1.
2.

The amount by which the survivor annuity that would have been payable under Civil Service Retirement System (CSRS) rules exceeds the
basic annuity payable under Federal Employees Retirement System (FERS) rules, or
The amount of a deemed widow/widower's Social Security benefit based on the service under FERS of the deceased.

The deceased retiree must have performed 5 years of service that could be creditable under FERS or CSRS rules, including one full calendar
year of service creditable under FERS rules.
You may be eligible for a survivor supplement if you are the surviving spouse of a retiree and you are:
1.

under age 60; and

2.

entitled to Social Security benefits at age 60; and

3.

not presently eligible for Social Security mother, father or disability benefits based on the deceased annuitant's account.

To help us determine your eligibility for a survivor supplement, you should provide the following information:
1.

Name of surviving spouse (last, first, middle initial)

3.

Are you disabled?

2.

Spouse's date of birth (mm/dd/yyyy)

3a. Are you eligible for Social Security disability benefits based on the deceased?

No, go to item 4.
Yes, go to items 3a and 3b.

Yes

No

Applied, but no response yet

Have not applied

Applied, but no response yet

Have not applied

Applied, but no response yet

Have not applied

3b. Do you receive Social Security disability benefits based on your own service?

Yes
4.

Yes

5.

No

Are you eligible for Social Security mother or father benefits based on the deceased retiree's service?

No, I know I do not qualify for these benefits as
there are no surviving dependent children under
age 16 or disabled who are entitled to SSA child's
insurance benefits.

If you are not currently receiving Social Security mother, father or disability benefits, do you agree to notify us promptly if you are later awarded any of these benefits?

Yes
6. Signature

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

No
7. Date (mm/dd/yyyy)

8. Telephone number (including area code)

Standard Form 3104A
Revised November 2019