Standard Form 3104 Documentation and Elections in Support of Application fo

OMB Approval 3206-0172

Documentation and Elections in Support of Application for Death Benefits when
Deceased was an Employee at the Time of Death
Federal Employees Retirement System
Includes Information, Instructions and Necessary Forms
Information for Agency
This package should be completed if the deceased was an employee under the Federal Employees Retirement System (FERS) at the time of
death. All applicable forms in the package should be submitted to the Office of Personnel Management (OPM) with the survivor's application,
Application for Death Benefits, SF 3104.

Information for Applicant
This package contains the forms that you and the employing agency of the deceased will need in order to complete your Application for Death
Benefits, SF 3104, under FERS. It should be completed only if the deceased was a Federal employee at the time of death. All applicable forms
in this package should be submitted to the employing agency of the deceased, along with your Application for Death Benefits, SF 3104.
The agency will forward the application to OPM.
Section 1: Certified Summary of Federal Service
To be completed by the employing agency personnel office of the deceased with applicant's signature certifying that information is complete.
Section 2: Basic Employee Death Benefit
To be completed by the employing agency personnel office of the deceased.
Section 3: Health Benefits Election
To be completed by the employing agency personnel office of the deceased and the applicant, if appropriate.
Section 4: Information and Elections Regarding Post-1956 Military Service
To be completed by applicant, if appropriate.
Section 5: Rollover Option and Death Benefit Payment Election Form
To be completed by the surviving spouse or surviving former spouse, if appropriate.
Section 6: Agency Information and Certification
To be completed by the employing agency personnel and payroll offices of the deceased.
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 Chapters 84, 87, 89, Title 5, U.S. Code and Public Law 102-318.
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 delay or prevent action on your application, or may result in Federal income tax withholding
from your benefit and may result in a rollover-eligible payment being made directly to you.
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.

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

Standard Form 3104B
Revised July 2020
Previous editions are not usable.

Section 1 - Certified Summary of Federal Service
Agency Instructions
A certified copy of this form must accompany an Application for Death Benefits, SF 3104 for a deceased employee if a survivor annuity or a
spousal lump sum death benefit appears to be payable.
Part A - Identification
1. Name of employee (last, first, middle initial)

3. Date of birth (mm/dd/yyyy)

4. Social security number

2. List all other names used (maiden name, AKA, spelling variants)

5. Other birth dates used

6. Military serial number

7. Service computation date for retirement purposes

8. Did employee elect to transfer to the Federal Employees Retirement
System (FERS)?
No

Yes, give effective date of election _________________

Part B - Verified Service History Documented in Official Personnel Records
Federal Agency or
Appointment, Separation, or
Name of Retirement
Military Service Branch
Conversion Dates for Civilian and
System*
Active Honorable Military Service

*
**

Remarks and Non-Creditable
Time**

Give details of creditable civilian service not subject to retirement deductions in Part C.
In Remarks, show if Civil Service Retirement System (CSRS) service on or after January 1, 1984, is "regular" CSRS or CSRS offset. If service was performed on a
When Actually Employed (WAE) or intermittent basis, show the number of hours worked in Remarks. If the service was part time, give the part time tour worked.

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Standard Form 3104B
Revised July 2020

Part C - Detail of Federal Civilian Service Not Subject to Contributory Retirement System
Detail below (1) any period of Federal civilian service subject to only Federal Insurance Contribution Act (FICA) deductions and (2) any other
Federal civilian service not subject to a Federal employee (or D.C. government) retirement system. If total basic salary earned for any such
period of service is known, a summary entry may be entered on the right hand side below. Otherwise, show each change affecting basic salary during the
period of service. Service which was not subject to Federal Employees Retirement System (FERS) or Civil Service Retirement System (CSRS) deductions is
creditable
Nature of action
(Appt, pro, res, etc.)

Effective date
(mm/dd/yyyy)

Basic
salary rate

Salary basis
(per annum, per hour, when
actually employed [WAE],
etc. Show part time tour,
if applicable.)

Leave
without pay

If Basic Salary Actually Earned is
Available, Make Summary Entry Below
From
(mm/dd/yyyy)

To
(mm/dd/yyyy)

Total
earned

Part D - Agency Certification
I certify that the information on this form accurately reflects verified information contained in official personnel and/or payroll records in the
custody of this agency.
Signature of authorized agency personnel official

Date (mm/dd/yyyy)

Agency name (including ZIP code)

Official title
Telephone number (including area code)

Fax number (including area code)

(

(

)

E-mail address (if applicable)

)

Part E - Applicant's Certification
To the best of my knowledge, the service listed above is complete.
The employee had additional service. (If you claim the employee had additional service, attach a signed statement giving dates, position
title and location of employment, including agency, bureau and division. Claimed service cannot be credited for survivor benefit purposes
until it has been verified, including unverified service listed on Statement of Prior Federal Service, SF 144, or similar affidavit.)
Note: If the employee performed Federal civilian service subject only to Social Security deductions (Federal Insurance Compensation
Act [FICA]) or not subject to retirement deductions, be sure that the agency has correctly completed Part C above.
Signature (do not print)

Date (mm/dd/yyyy)

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Standard Form 3104B
Revised July 2020

Section 2 - Basic Employee Death Benefit (BEDB)

Agency Instructions
Method of Payment of BEDB - The surviving spouse of an employee who dies in service is entitled to the BEDB if:
a.

the employee completed at least 18 months of civilian service, and

b.

the surviving spouse was married to the employee for an aggregate of at least 9 months.

The 9-month marriage requirement does not apply if the surviving spouse is the natural parent of the employee's child (including a posthumous
child or one born out of wedlock), or if the employee's death was accidental.
The amount of the BEDB is $15,000 (increased by Civil Service Retirement System [CSRS] Cost of Living Adjustments [COLAs]), plus 50% of
the employee's final annual rate of pay (or average salary, if higher).
The current BEDB value can be found in this year's "Annual Changes" Benefits Administration Letter, found on www.opm.gov.
For a part-time (regularly scheduled) employee, the final annual rate of pay is the basic pay, at the rate in effect immediately before the
employee's death, that is applicable to the employee's tour of duty (or, if higher, the hours in a basic pay status) in the 52-week work year
immediately preceding the end of the last pay period the employee was in a pay status. For example, a part-time employee who, at the time of
his/her death, was being paid at the annual rate of $30,000, but whose tour of duty was 20 hours a week, would have a final annual pay rate of
$15,000 for purposes of the BEDB. However, if the same employee actually earned basic pay during 1144 hours (averaging 22 hours per
week) in the 52-week work year, the final annual rate of basic pay would be $16,500 (22/40 x $30,000). If this employee were paid on an
hourly basis at $14.00 per hour, the final annual rate of basic pay would be $16,016 (1144 hours x $14.00).
To determine the final annual pay rate of an intermittent (not regularly scheduled) employee, the employee's final hourly rate of pay is
multiplied by the number of hours he or she worked at basic pay rates (up to full time) in the 52-week work year immediately preceding the
end of the last pay period the employee was in a pay status.
Note: The Basic Employee Death Benefit (BEDB) is payable (in whole or in part) to a former spouse if a qualifying court order is on file at the
Office of Personnel Management (OPM), and the former spouse was married to the employee for an aggregate of at least 9 months.
Elections That the Survivor Must Make - The surviving spouse must elect whether to receive the Basic Employee Death Benefit (BEDB) in
a lump sum or in 36 monthly installments. To make an election, he or she should complete Part 1 of the Death Benefit Payment Election Form
(on page 15) in Section 5 of this forms package. The employing agency needs to enter the amount payable on the following page, so the
survivor has the information necessary to make this election. To determine the amount of a monthly installment, multiply the total amount of
the lump-sum benefit by .0301643. (The factor for computing the installments is specified in 5 CFR 843.309 and may be adjusted periodically.
Check the regulations for the current factor before computing the amount of the monthly installment payments.)
If the surviving spouse is eligible to receive the BEDB, he/she will also need to complete the election concerning the rollover option in Part 2
of the Death Benefit Payment Election Form (on page 15), found in Section 5 of this forms package. The BEDB is subject to special provisions
of the law which allow recipients to roll over all or part of the benefit into an Individual Retirement Arrangement (IRA) or eligible employer
plan, whether paid as a one-time lump sum or in 36-installments.
Please advise the applicant to read the information in Section 5 carefully, before making these elections.

Previous editions are not usable.

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Standard Form 3104B
Revised July 2020

Applicant Information
If the widow(er) of a Federal employee was married to a Federal employee for at least 9 months and the Federal employee had at least 18
months of creditable civilian service, the widow(er) is entitled to a Basic Employee Death Benefit (BEDB) equal to:
50 percent of the employee's final salary (or average salary, if higher)

►

plus
$15,000 (increased by Civil Service Retirement System [CSRS]
Cost of Living Adjustments [COLAs])

►

The benefit due in your case is

► $

If you wish, you can choose to receive it in 36 monthly installments of $_________________________ instead of a single lump sum. Note that
the total amount paid in installments will be slightly higher than the single lump sum because interest is paid on the installments to give you an
amount approximately equal (because of inflation) to the single lump sum. After installments have begun, you can ask the Office of Personnel
Management (OPM) to stop the monthly payments, and pay you the remaining amount of the benefit in a single lump sum (your request must
be made in writing). However, no interest will be paid on the remaining benefit after the date of the last installment. In other words, the balance
paid will not equal the sum of the remaining installments.
You have two decisions to make 1. You must make your choice about the method of payment of the BEDB (lump sum or 36 installments) in Part 1 of the Death Benefit
Payment Election Form (on page 15), found in Section 5 of this forms package.
2. You must make an election to either have all or a part of any eligible benefit paid directly to you or rolled over into an Individual
Retirement Arrangement (IRA) or eligible employer plan, in Part 2 of the Death Benefit Payment Election Form (on page 15), found in
Section 5 of this forms package. It is very important that you read the information in Section 5, because it explains this option.
Please note:
In the case of part-time and intermittent employees, the benefit is prorated.

►
►

If the employee had a former spouse who has on file at OPM a qualifying court order that awards some or all of the BEDB to the former
spouse, your benefit cannot exceed the difference between the amount shown above and the portion of that benefit payable to the former
spouse. OPM will notify you if your benefit will be less than the one shown for this reason.

►

If the employee had service for which no retirement deductions were withheld and a deposit must be made to meet the minimum service
requirement for a death benefit, that deposit will be withheld from your BEDB before any amount is payable.

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Standard Form 3104B
Revised July 2020

Section 3 - Health Benefits Election
Agency Instructions
If the surviving spouse of a deceased employee is not eligible for monthly survivor annuity benefits (because the employee had less than 10
years of creditable service), he or she can still elect to continue health benefits coverage, provided:
a.

the surviving spouse is eligible for the Basic Employee Death Benefit described in Section 2, and

b.

the employee was enrolled under the Federal Employees Health Benefits (FEHB) program with self-and-family coverage at the time of
death.

If the surviving spouse elects to continue health benefits coverage, he or she must pay the premiums directly to the National Finance Center
(NFC), since there is no monthly survivor annuity from which to withhold the premiums. The Office of Personnel Management (OPM) will
consider withholding premiums from the Basic Employee Death Benefit if the survivor elects to receive the payment in 36 monthly
installments. (See Section 2.) To make the election whether or not to continue coverage, the spouse must complete the election below.
When the surviving spouse is eligible for and elects to continue health benefits coverage, the personnel office must (1) forward file copies of all
Employee Health Benefits Election Form, SF 2809's and Notice of Change in Health Benefits Enrollment, SF 2810's to OPM; (2) attach any
medical determinations made for continued coverage of disabled children; and (3) forward to OPM with the Individual Retirement Record
(IRR), SF 3100, all copies of Designation of Beneficiary, SF 3102 on file, Application for Death Benefits, SF 3104, all applicable forms in
Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death, SF 3104B
and related documents.
Employing agency must check one of the following:
1.

Surviving spouse needs to complete the election below because the employee had at least 18 months of civilian service, but less than
10 years of total creditable service, and the surviving spouse meets the requirements for continuation of FEHB coverage. (Count all
creditable civilian and military service.)

2.

Section not applicable because employee had more than 10 years of creditable civilian and military service. This 10 years included at
least 18 months of civilian service.

3.

Section not applicable because employee was not enrolled in a self-and-family plan or not enrolled for health benefits.

Applicant Instructions
If item 1, above, is checked, surviving spouse must make the election described below:
If you are not entitled to a monthly survivor annuity benefit (your spouse had less than 10 years of creditable service), but your spouse had at
least 18 months of civilian service and was enrolled in a self-and-family plan at death, you may still be eligible to continue the health benefits
enrollment. You must make payments on a monthly basis to cover the cost of your premiums. If you want to continue this coverage, OPM will
send you instructions for making payments according to your election. Indicate your choice below.
I elect to continue my spouse's health benefits enrollment. I will make payments to cover the cost of this enrollment after I receive
instructions on how to do so. I realize that I must pay the premium on or before the first day of each month for coverage during the
preceding month. I understand that if my payment is not received by the due date, my enrollment may be terminated with no right
to reenroll.
I elect not to continue my spouse's health benefits enrollment. I realize that this election cannot be changed at a later date.

Signature

Date (mm/dd/yyyy)

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Standard Form 3104B
Revised July 2020

Section 4 - Information and Elections Regarding Post-1956 Military Service
This section should be completed if:
►

The deceased was an employee at the time of death and performed active duty military service after December 31, 1956; and

►

A deposit to pay for such service was not completed with the deceased person's employing agency prior to his/her death; and

►

The deceased is survived by a spouse or former spouse eligible to receive a Federal Employees Retirement System (FERS) survivor annuity.

or
►

The deceased was receiving military retired pay and is survived by a spouse or former spouse eligible to receive a FERS survivor annuity.

Information About Credit for Post-1956 Military Service for the Survivor of a Deceased FERS Employee
Because your decision about completing the deposit for or including the deceased employee's military service in the survivor annuity
computation may affect your rights under FERS, you need to be aware of the following information.
A. If the Deceased Employee Qualified for a Civil Service Retirement System (CSRS) Component
(a portion of a FERS annuity payable that is computed under CSRS rules)
1.

If the military service was performed before the deceased employee was covered by FERS, you will receive credit for the
military service in the CSRS component of the FERS benefit in accordance with the following:
a.

If the deceased was first employed in a position under CSRS before October 1, 1982:
(1) If you qualify at the deceased employee's death, for Social Security survivor benefits based on his/her military service, you
have the option of either making the deposit so that the post-1956 military service will be included in the survivor annuity
computation or not making the deposit and excluding the post-1956 military service from the survivor annuity computation.
(2) If you will qualify at a future date for Social Security benefits based on the deceased person's service, post-1956 military
service will be included in the computation of your survivor annuity until you become eligible (or would upon application
be eligible) for Social Security survivor benefits. You have the option of either making the deposit now and avoiding a
reduction in your FERS survivor annuity, or not making the deposit and having your annuity adjusted to exclude post-1956
military service when you become eligible for Social Security survivor benefits based on the deceased person's service.

Note:

b.
2.

Eligibility for Social Security benefits. A survivor of a deceased employee may be eligible for Social Security survivor benefits
if the employee was "fully insured" and the survivor is (a) the parent of an eligible child, (b) age 50 or over and disabled,
(c) age 60 or over, or (d) a divorced spouse age 62 or over. For information about your present or future eligibility for Social
Security survivor benefits, contact the Social Security Administration. If you become ineligible for Social Security benefits
based on the deceased employee's service (e.g., by becoming eligible for Social Security benefits based on your own earnings
which exceed the survivor benefits), you should contact the Office of Personnel Management (OPM). You may be eligible to
have the military service restored to the survivor annuity computation.
If the deceased was first employed in a position under CSRS after September 30, 1982, you must make the deposit for
post-1956 military service in order to receive credit for the service.

If the military service was performed after the deceased was covered by FERS, you will receive credit for the military service
according to the rule stated in paragraph B for FERS employees.

B. If the Deceased Employee did not Qualify for a CSRS Component in a FERS Benefit, you will not receive credit for the post-1956
military service for any purpose (including the ten years of service needed for entitlement to survivor annuity) unless the deposit is paid.

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Standard Form 3104B
Revised July 2020

C. Effect of Military Retired Pay on Creditability of Military Service Regardless of When the Deceased Was First Employed
1.

If, at the time of death, the employee was receiving military retired or retainer pay that was awarded because of a service-connected
disability incurred either in combat with an enemy of the United States or caused by an instrumentality of war and incurred in the line
of duty during a period of war, or awarded under the reserve retiree provisions (chapter 1223, title 10, U.S. Code, formerly chapter 67,
title 10, U.S. Code), you will receive credit for the military service subject to the provisions for military deposit for post-1956 military
service.

2.

If, at the time of death, the employee was receiving military retired or retainer pay that was not awarded under either of the two
exceptions noted in C.1. above, you will also receive credit for the military service subject to the provisions for military deposit for
post-1956 military service. However, there will be a difference in the computation as described below.
a.

If you qualify for benefits under this provision, and the deceased employee arranged for you to receive a survivor benefit from the
military, the military survivor benefit will not be affected by your eligibility to receive a Federal Employees Retirement System
(FERS) survivor benefit, but it will be necessary for the Office of Personnel Management (OPM) to reduce your FERS survivor
annuity by an amount equal to the survivor benefit you will receive from the military. The amount deducted from your FERS
survivor benefit will never reduce it below the amount of the FERS survivor benefit based on the deceased employee's civilian
service alone, however.

b.

If you feel that it is not to your advantage to include the military service in the computation of the FERS survivor benefit,
you may send OPM your written election not to include the military service in your FERS survivor annuity computation now.
(See Part C of the "Survivor's Military Service Election" form on page 10.)

D. Other Information about Deposit for Military Service
1.

The amount of the deposit is 7 percent of military basic pay (plus interest, if any) if the deceased employee transferred to FERS but
his/her military service will be credited under CSRS rules. (See A.1. on page 6.)

2.

The amount of the deposit if the deceased employee's military service will be credited under FERS rules (see B. on page 6.) is:

3.

►

3% of military basic pay (plus interest, if any) for service performed through 12/31/98;

►

3.25% of military basic pay (plus interest, if any) for service performed from 1/1/99 through 12/31/99;

►

3.4% of military basic pay (plus interest, if any) for service performed from 1/1/00 through 12/31/00; and

►

3% of military basic pay (plus interest, if any) for service performed from 1/1/01 to the present.

If the deposit is made, the post-1956 military service will be credited under both the Federal Employees Retirement System and the
Social Security System, if it is otherwise creditable.

E. If You Elect to Pay the Deposit
1.

If you do not have sufficient documentation of the deceased employee's military basic pay earnings for the employing agency to
determine the amount due, the agency will tell you how to obtain an estimate of earnings from the branch of military service in
which the deceased served.

2.

Payment should be made to the agency as soon as possible. The agency will continue processing your application for death benefits
while you are waiting to receive an estimate of military earnings from the military service. If you have not made the deposit before
the agency sends the application to OPM, the agency will tell OPM that you plan to pay the deposit.

3.

In order to credit your deposit, OPM must receive documentation of your payment from the agency before your application is
completely processed.

4.

If you elect to pay the deposit, but later decide not to do so, promptly notify the employing agency and OPM in writing so that final
processing of your application for survivor benefits can take place.

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Standard Form 3104B
Revised July 2020

This Page
is
Intentionally
Blank.

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Standard Form 3104B
Revised July 2020

Survivor's Military Service Election
Deceased Employee Covered by the Federal Employees Retirement System (FERS)
Part A - To be completed by employing agency before survivor completes elections in Parts B and C
1. Deceased employee's name (last, first, middle initial)

2. Date of birth (mm/dd/yyyy)

3. Social security number

4. Was a deposit account opened for the employee?
Yes, give information requested below

Period of military service
From (mm/dd/yyyy)

No
Amount due (with interest)

Balance due

$

$

To (mm/dd/yyyy)

5. Agency records indicate that the above named employee had post-1956 military service for which deposit has not been completed.

Records also show that the employee--

Qualified for a Civil Service Retirement System (CSRS) component in a FERS benefit and performed military service before being covered by FERS
and was --

First employed under CSRS before October 1, 1982; or
First employed under CSRS on or after October 1, 1982.
Qualified for a CSRS component in a FERS benefit and performed military service after being covered by FERS.
Did not qualify for a CSRS component in a FERS benefit.
6. Name of agency representative to contact for information (last, first, middle initial)

Telephone number and area code

7. Agency personnel office address to which form should be returned

(
)
Date (mm/dd/yyyy) election should be received by
[30 days from date form is given to applicant]

Part B - Deposit Election (to be completed by survivor)
Our records indicate that you might be eligible for a survivor annuity. You have the right to make a deposit for the deceased employee's
post-1956 military service. Your decision may affect your rights under FERS. Read "Information About Credit for Post-1956 Military Service
for the Survivor of a Deceased FERS Employee" on page 6, carefully to be sure you understand the consequences of including the military
service or of not making the deposit. Then make your election, sign and date the form, and return two copies to the employing office shown in
item 7 above.
If you decide to pay the deposit, the employing agency of the deceased employee will provide you with the necessary information.
Payment must be made in a lump sum to the employing agency of the deceased employee before the Office of Personnel Management
(OPM) completes the processing of your application.
I have read this information concerning my right to make a lump sum deposit to the employing agency of the deceased employee for post-1956
military service. (Note: An election to make a deposit may be changed at any time before the deposit is actually paid to the agency.)
I elect to make (or complete) the deposit to the employing agency of the deceased employee for the post-1956 military service.
I understand that this deposit must be paid to the agency in a lump sum within 30 days after the agency notifies me of the amount due.
I elect not to make (or complete) the deposit for post-1956 military service. I understand this decision may not be changed at a later date.

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Standard Form 3104B
Revised July 2020

Part C - Election to Exclude Military Service from the Annuity (to be completed by survivor of deceased employee
who is in receipt of military retired pay at time of death)
If the deceased employee received military retired or retainer pay that was not (1) awarded because of a service-connected disability incurred
either in combat with an enemy of the United States or caused by an instrumentality of war and incurred in the line of duty during a period of
war, or (2) awarded under reserve retiree provisions (chapter 1223, title 10, U.S. Code, formerly chapter 67, title 10, U.S. Code), you will
receive credit toward your Federal Employees Retirement System (FERS) survivor benefit for the military service subject to the rules for
post-1956 military deposits. However, if you do receive credit for military service (including any pre-1957 military service), your FERS
survivor benefit must be reduced by the amount of any military survivor benefits payable to you. In some instances, it may not be
advantageous to receive a survivor benefit including the military service in the computation.
In order to compute your survivor annuity benefits, we need to know if you are eligible for military survivor benefits. If you are eligible to
receive military survivor benefits, we need to know if you want to exclude the deceased person's military service from the computation of
your FERS survivor benefit.
Are you entitled to receive military survivor benefits?
No
Yes. Specify monthly amount (if know), and attach documentation, if available.
$______________________
Credit for military service will be included in the computation of your FERS survivor annuity benefit unless you elect below to exclude it.
Do not use my deceased spouse's (former spouse's) military service in determining my FERS survivor annuity.

Part D - Signature
Signature

Date (mm/dd/yyyy)

10

Standard Form 3104B
Revised July 2020

Section 5 - Rollover Option Information for Lump Sum Benefits Payable to a Surviving Spouse or
Surviving Former Spouse
Please read the following information carefully, along with the information that the employing agency of the deceased has provided in Section
2, page 3 (Basic Employee Death Benefit [BEDB]). You will need to make some important elections regarding the payment of your benefits,
based on this information.
Some lump sum death benefits payable to a surviving spouse or a former spouse (who is named under a court order that properly apportions
benefits under the Federal Employees Retirement System [FERS] law) can be rolled over into a traditional Individual Retirement Arrangement
(IRA), a Roth IRA or an eligible employer plan. Lump sums that can be rolled over are:
1.

The BEDB, whether paid in a lump sum or in 36 installments.

2.

Employee contributions, excess retirement deductions and/or voluntary contributions, and any interest payable on these amounts.

The entire BEDB is taxable. Any interest payable on refunded employee contributions, excess retirement deductions and voluntary
contributions is also taxable. The actual refunded employee contributions, excess retirement deductions and voluntary contributions are
not taxable amounts and are referred to as non-taxable or after-tax amounts.
If the total lump sum payable to you is $200 or more, you can ask the Office of Personnel Management (OPM) to pay all or part of it to
your IRA or eligible employer plan as a direct rollover. If you roll over the funds to a traditional IRA or eligible employer plan, you will
not be taxed on any taxable amount rolled over until you take the money out of the IRA or employer plan. If you roll over the funds to a
Roth IRA, you cannot postpone taxation of the taxable portion.
To avoid the 20 percent tax withholding on taxable lump sums over $200, you must elect for OPM to pay them to your traditional IRA account
or eligible employer plan. While the check would be made payable to your IRA or plan, at your instruction, we will send the payment directly
to your account or to you for deposit into your account. You must specifically state the amount you want rolled over by electing "all" or a
smaller amount on the enclosed election form.
If you elect to roll over less than "all" of any taxable lump sum(s) payable to you, you must elect to roll over at least $500. OPM will not roll
over a partial amount of less than $500. If your total taxable amount is less than $500, you can only elect to roll over "all."
You can elect to personally be paid all or part of any taxable lump sum, however, OPM is required to withhold for Federal income tax 20
percent of the taxable amount that is not rolled over.
If you elect not to roll over all or part of any taxable lump sum, we will withhold 20 percent of the benefit we pay to you for transmittal to
the Internal Revenue Service. You have the option to personally roll over any taxable lump sum that is paid to you to your IRA or eligible
employer retirement plan within 60 days after you receive it. If you decide to do this, and you roll over the funds to a traditional IRA or
employer plan, you do not credit the money as taxable income until it is withdrawn from your IRA or plan. You cannot postpone taxation
of amounts rolled into a Roth IRA.
If your total lump sum is less than $200, OPM will not withhold any amount for Federal income tax on the payment. Although we will not
roll over amounts of less than $200 to an IRA or eligible employer plan, you can personally deposit any lump sum into an IRA or eligible
employer plan as a direct rollover within 60 days after you receive it. The taxable portion of the lump sum is taxable in the year it is
received unless it is deposited into a traditional IRA or eligible employer plan.

Extra Information for Recipients of the BEDB Who Elect Payment in Monthly Installments
All of the BEDB, when paid in a lump sum or monthly installments, is taxable. If you elect to roll over part of each monthly installment into
an IRA or eligible employer plan, the monthly amount rolled over to each IRA or plan must be equal to at least $500. You may change your
election regarding this rollover at any time in the future while still receiving BEDB installments. You must write to us at the time you want to
change your election. Your election will take effect with the monthly benefit payable at the time the request is received. You cannot take a
partial payment of the lump sum now and receive the remainder in installments.
While receiving BEDB installments you can elect to:
► stop payments to an IRA or eligible employer plan.
►

begin payments to an IRA or eligible employer plan.

►

change the amount rolled over to the IRA or eligible
employer plan.

►

change the financial institution that will administer your direct
rollover payments.

►

stop installment payments and receive the remainder as a lump
sum.

Tax Information
Please refer to the attached notice regarding Federal income tax. If you have further questions specifically about the taxability of these benefits,
you should contact a qualified tax advisor or the Internal Revenue Service (IRS). This is the only income tax information available from OPM
on the subject.
If you decide to roll over a non-taxable payment to an IRA, you are responsible for keeping track of the taxable and non-taxable amounts in
the IRA. If you roll over a non-taxable payment to an eligible employer plan, the plan must certify that it is willing to accept the payment in a
trustee to trustee transfer and to separately account for taxable and non-taxable portions of the rollover.
Please note that if you receive a taxable benefit in addition to any lump sum payable to you (such as a monthly survivor annuity or benefits
for a surviving child), the 20 percent withholding rules do not apply to taxable benefits not eligible for rollover. In those cases, you may elect
not to have tax withholding apply to those payments by calling OPM on 1-888-767-6738. You can also write to us at: U.S. Office of Personnel
Management, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045.
Previous editions are not usable.

11

Standard Form 3104B
Revised July 2020

Special Tax Notice Regarding Rollovers
This notice explains how a surviving spouse or a surviving former spouse (named under a court order that properly apportions benefits under
the Federal Employees Retirement System (FERS) law) can defer federal income tax on their lump-sum payment and contains important
information they will need before they decide how to receive their payment.
This notice is provided because all of the Basic Employee Death Benefit (whether paid in a lump sum or in 36 installments), any lump sum
payments of employee contributions, excess retirement deductions and voluntary contributions and any interest payable on these amounts
are eligible for rollover to a traditional IRA, a Roth IRA or an eligible employer plan. A rollover is payment by you or OPM of all or a part of
your lump sum benefit to an eligible employer plan or IRA. A rollover to a traditional IRA or eligible employer plan allows you to continue to
postpone taxation of the lump sum until it is paid to you. You cannot postpone taxation of the taxable portion of your payment if you roll it
over to a Roth IRA. Your payment cannot be rolled over to a SIMPLE IRA or a Coverdell Education Savings Account (formerly known as an
education IRA). An "eligible employer plan" includes a plan qualified under section 401(a) of the Internal Revenue Code, including a 401(k)
plan, profit-sharing plan, defined benefit plan, stock bonus plan, and money purchase plan; a section 403(a) annuity plan; a section 403(b)
An eligible employer plan is not legally required to accept a rollover. Before you decide to roll over your payment to an employer plan, you
should find out whether the plan accepts rollovers and, if so, the types of distributions it accepts as a rollover. You should also find out about
any documents that must be completed before the receiving plan will accept a rollover. Even if a plan accepts rollovers, it might not accept
rollovers of certain types of distributions, such as after-tax amounts. If this is the case and your distribution includes after-tax amounts, you
may wish instead to roll your distribution over to a traditional or Roth IRA or split your rollover amount between the employer plan in which
you will participate and a traditional or Roth IRA. If an employer plan accepts your rollover, the plan may restrict subsequent distributions of
the rollover amount or may require your spouse's consent for any subsequent distribution. A subsequent distribution from the plan that accepts
your rollover may also be subject to different tax treatment than distributions from OPM. Check with the administrator of the plan that is to
receive your rollover prior to making the rollover.
If you have a Federal Retirement Thrift Savings Plan account, you may roll over the taxable portion of your lump sum into that account.
The Thrift Savings Plan (TSP) will not accept non-taxable (after-tax) monies. To accomplish a rollover to the TSP, you will need to
submit form TSP-60 with this form. See Part II Direct Rollover for more information.

Summary
There are two ways you may be able to receive a payment that is eligible for rollover:
1.
2.

We can make certain payments directly to a traditional or Roth IRA that you establish or to an eligible employer plan that will accept it
and hold it for your benefit (Direct Rollover); or
We can make the payment to you.

If you choose a direct rollover of the taxable portion or all of your benefit ►

The taxable portion of your payment will not be taxed in the year it is paid, and we will not withhold income tax, if it is rolled over to a
traditional IRA or eligible employer plan.

►

The taxable portion of your payment made directly to your Roth IRA is taxable income in the year in which the rollover is paid.
OPM will not withhold income tax unless you elect that 20% tax be withheld on the Death Benefit Election form.

►

You choose whether your payment will be made directly to your traditional or Roth IRA or to an eligible employer plan that accepts your
rollover. Your payment cannot be rolled over to a SIMPLE IRA or a Coverdell Education Savings Account because these are not
traditional IRA's.

►

The taxable portion of your payment, if rolled over to a traditional IRA or eligible employer plan, will be taxed later when you take it
out of the traditional IRA or the eligible employer plan. Distributions from the plan to which the rollover is made may be subject to
different restrictions and tax consequences than those that apply to distributions from OPM. You must pay tax on the taxable portion
rolled into a Roth IRA in the year in which the rollover is made.

If you choose to have the taxable portion of your benefit paid to you ►

You will receive only 80% of the taxable portion of the payment, because OPM is required to withhold 20% of the taxable payment and
send it to the IRS as income tax withholding to be credited against your taxes.

►

Your payment will be taxed in the year it is paid unless you roll it over.

►

You can roll over the payment by paying it to your traditional IRA, a Roth IRA or an eligible employer plan that accepts your rollover
within 60 days after you receive the payment. The amount rolled over will not be taxed until you take it out of the traditional IRA or
eligible employer plan. You cannot postpone taxation of amounts rolled over into a Roth IRA, even if you roll it over into a Roth IRA
within 60 days.
If you want to roll over 100% of the payment, you must find other money to replace the 20% that was withheld. We cannot refund the
20% once it has been withheld. If you roll over only the 80% you receive, you will be taxed on the 20% that was withheld and not rolled
over.

►

12
Standard Form 3104B
Revised July 2020

If you are a surviving spouse or former spouse who can receive a rollover-eligible benefit because of an order issued by a court, usually in
connection with a divorce or legal separation, you may choose to have an eligible rollover distribution paid to an IRA or eligible employer
plan or have it paid to you. If you have the payment paid to you, you can keep it or roll it over into an IRA or employer plan yourself.
If you are a beneficiary other than a surviving spouse or a surviving former spouse listed in a court order, you cannot choose a direct rollover,
and you cannot roll over the payment yourself.

More Information
I.

Payments that cannot be rolled over
Payments Spread Over Long Periods. You cannot roll over a payment if it is part of a series of equal (or almost equal) payments that
are made at least once a year and that will last for
► your lifetime (or your life expectancy), or

II.

►

your lifetime and your beneficiary's lifetime (or life expectancies), or

►

a period of ten years or more.

Direct Rollover
A direct rollover is a direct payment of your lump sum to a traditional IRA, a Roth IRA or an eligible employer plan that will accept it.
You can choose a direct rollover of all or any portion of your payment. You are not taxed on a payment until you later take it out of the
traditional IRA or the eligible employer plan. You cannot postpone taxation of amounts rolled into a Roth IRA. OPM will not pay a
direct rollover or withhold tax on taxable payments under $200, but recipients themselves may roll over such payments within 60 days
after receipt. The minimum direct rollover amount is $500 if you designate part of your payment as a direct rollover with the remainder
payable to you.
Direct Rollover to a Traditional IRA or a Roth IRA. You can open a traditional IRA or Roth IRA to receive the direct rollover.
If you choose to have your payment made directly to a traditional or Roth IRA, contact an IRA sponsor (usually a financial institution)
to find out how to have your payment made in a direct rollover to an IRA at that institution. If you are unsure of how to invest your
money, you can temporarily establish an IRA to receive the payment. However, in choosing a traditional IRA, you may want to make
sure that the IRA you choose will allow you to move all or part of your payment to another IRA at a later date, without penalties or other
limitations. See IRS Publication 590, Individual Retirement Arrangements, for more information on IRAs (including limits on how often
you can roll over between IRAs). Note: If you elect to place any non-taxable portion of the rollover from OPM in an IRA, you are
responsible for accounting separately for the taxable and non-taxable portions of the rollover.
Direct Rollover to an Eligible Employer Plan. If you are employed by an employer that has an eligible employer plan and you want a
direct rollover to that plan, ask the administrator of that plan whether it will accept your rollover. An eligible employer plan is not legally
required to accept a rollover. If your employer's retirement plan does not accept a rollover, you can choose a direct rollover to a
traditional or Roth IRA. If the employer plan accepts your rollover, the plan may have restrictions on the circumstances under which
you may later receive a distribution of the rollover amount or may require spousal consent to any subsequent distribution. Check with
the plan administrator before making your decision. Note: If you elect to place any non-taxable portion of the rollover from OPM in
an employer retirement plan, the plan is responsible for accounting separately for the taxable and non-taxable portions of the rollover.
Direct Rollover of a Series of Payments. If you receive eligible rollover distributions that are paid in a series for less than 10 years,
your choice to make or not make a direct rollover for a payment will apply to all later payments in the series unless you change your
election. You are free to change your election for any later payment in the series by contacting OPM.
Change in tax treatment resulting from a direct rollover. The tax treatment of any payment from the eligible employer plan or IRA
receiving your direct rollover might be different than if you received your lump sum in a taxable distribution directly from OPM.
Direct Rollover to the Thrift Savings Plan (TSP). If you choose to roll part or all of the taxable portion of your distribution into your
TSP account, you need to submit form TSP-60, Request for Transfer Into the TSP, along with the Death Benefit Payment Election Form
in this package. TSP-60 is available on the internet at www.tsp.gov/forms.

13
Standard Form 3104B
Revised July 2020

III. Payment Paid to You
If you have the payment made to you, the taxable portion is subject to 20% Federal income tax withholding. The payment is taxed in the
year you receive it unless, within 60 days after receiving it, you roll it over to a traditional Individual Retirement Arrangement (IRA) or
an eligible employer plan that accepts rollovers. You are taxed on any taxable portion rolled into a Roth IRA in the year in which the
rollover is made. Any part of the payment you do not roll over is taxed in the year you receive it, and special tax rules may apply.
Mandatory Federal Income Tax Withholding. If any portion of your payment is taxable and you do not elect a direct rollover or roll
over the payment within 60 days (see below), the Office of Personnel Management (OPM) is required by law to withhold 20% of the
taxable amount. This amount is sent to the Internal Revenue Service (IRS) as income tax withholding. For example, if the taxable portion
of your eligible rollover distribution is $10,000, only $8,000 will be paid to you because OPM must withhold $2,000 as income tax.
However, when you prepare your income tax return for the year, you will report the full $10,000 as payment from OPM. You will report
the $2,000 as tax withheld, and it will be credited against any income tax you owe for the year.
Sixty-Day Rollover Option. If you have a rollover distribution paid to you, you can still decide to roll over all or part of it to a
traditional IRA, a Roth IRA or eligible employer plan that accepts rollovers. If you decide to roll it over, you must make the rollover
within 60 days after you receive the payment. The taxable portion of your payment that is rolled over to a traditional IRA or an eligible
employer plan will not be taxed until you take it out of the IRA or the eligible employer plan. You are taxed on any taxable portion
rolled into a Roth IRA in the year in which the rollover is made.
You can roll over up to 100% of the payment, including an amount equal to the 20% that was withheld for federal tax. If you choose to
roll over 100%, you must find other money within the 60-day period to contribute to the IRA or plan to replace the 20% that was
withheld. On the other hand, if you roll over only the 80% that you received, you will be taxed on the 20% that was withheld.
Example: The taxable portion of your payment is $10,000, and you choose to have it paid to you. You will receive $8,000, and $2,000
will be sent to the IRS as income tax withholding. Within 60 days after receiving the $8,000, you may roll over the entire $10,000 to a
traditional IRA or eligible employer plan. To do this, you roll over the $8,000 you received from OPM, and you will have to find $2,000
from other sources (your savings, a loan, etc.). In this case, the entire $10,000 is not taxed until you take it out of the IRA or employer
plan. If you roll over the entire $10,000, when you file your income tax return you may get a refund of the $2,000 withheld.
If, on the other hand, you roll over only $8,000, the $2,000 you did not roll over is taxed in the year it was withheld. When you file your
income tax return, you may get a refund of part of the $2,000 withheld. (However, any tax refund is likely to be larger if you roll over
the entire $10,000.)

How to Obtain Additional Information
This notice summarizes only the Federal (not State or local) tax rules that might apply to your payment. The rules described above are complex
and contain many conditions and exceptions that are not included in this notice. Therefore, you may want to consult with a professional tax
advisor before you take a payment of your benefits from OPM. Also, you can find more specific information on the tax treatment of payments
from eligible employer plans in IRS Publication 575, Pension and Annuity Income, IRS Publication 590, Individual Retirement Arrangements,
and IRS Publication 721, Tax Guide to U.S. Civil Service Retirement Benefits. These publications are available from your local IRS office, on
the IRS's website at www.irs.gov, or by calling 1-800-TAX-FORMS.

14

Standard Form 3104B
Revised July 2020

Death Benefit Payment Election Form
For Completion by Surviving Spouse or by a Former Spouse Named Under a Court Order
Name of surviving spouse (last, first, middle initial)

Complete Part 1 and Part 2 below and sign the certification section on the bottom of the form.
Part 1 - Method of Payment of Basic Employee Death Benefit (BEDB) [For specific dollar amounts payable refer to information
provided by the deceased's employing agency in Section 2 (Basic Employee Death Benefit) on page 4 of this package of forms.]
I elect to receive my BEDB payment in:
A Lump Sum

36 Installments

Part 2 - Death Benefit Payment Rollover Election - Select one of the following options.

Option 1
Pay any benefits eligible for a rollover directly to me. I do not want to roll over these benefits into an Individual Retirement Arrangement (IRA) or
eligible employer plan. I understand that 20% of the taxable amount of the payment(s) will be withheld for tax but that I can roll over part or all of the
taxable amount to a qualified account within 60 days to defer income tax.

Option 2
I want to roll over all or part of my eligible benefits into an IRA, eligible employer plan or Thrift Savings Plan account. Answer items A and B and have
Certification by Financial Institution or Eligible Employer Plan completed by your financial institution or employer plan. If you are rolling over your
death benefit into your Thrift Savings Plan (TSP) account, the TSP does not need to complete the Certification by Financial Institution or Eligible
Employer Plan.
Item A - Amount to roll over into my IRA, eligible employer plan or Thrift Savings Plan account: (Please state all or the specific amount in each category
below. If you roll over less than all of the rollover to one institution, the total payment to each IRA, employer plan, or your Thrift Savings Plan (TSP)
account must be at least $500.)
Roll the following amount over to ________________________________________________________________________________________
(Name of IRA/Plan)
This rollover is to a Roth IRA

Withhold 20% income tax from amount rolled over to Roth IRA

BEDB Monthly $____________________ of the taxable amount
Installment

Lump Sum $____________________ of the taxable amount
$____________________ of the non-taxable amount

(All of the BEDB
amount is taxable)

Roll the following amount over to ________________________________________________________________________________________
(Name of IRA/Plan)
This rollover is to a Roth IRA

Withhold 20% income tax from amount rolled over to Roth IRA

BEDB Monthly $____________________ of the taxable amount
Installment

Lump Sum $____________________ of the taxable amount
$____________________ of the non-taxable amount

(All of the BEDB
amount is taxable)

If I elect to roll over less than all, I understand that the taxable portion of any balance made payable to me will be subject to 20% tax withholding and that
I can roll any part of it over to a qualified account within 60 days to defer income tax.
Item B - I want to have the rollover amount sent: (Check one box below)
Directly to my financial institution

To me, made payable to my account. I will deliver it to the account.

Option 3
I do not want to make an election at this time. I want the Office of Personnel Management (OPM) to send me the complete rollover election package if I
am eligible to receive a taxable lump sum of over $200. I understand my application for benefits will not be processed until after I receive and return the
election forms.
Certification of Your Selections
By my signature below, I certify that I have made the elections shown above and that I have read and understand the information in the accompanying
Rollover Option Information and Special Tax Notice Regarding Rollovers.
Signature

Previous editions are not usable.

Social Security Number

15

Date (mm/dd/yyyy)

Standard Form 3104B
Revised July 2020

Certification by Financial Institution or Eligible Employer Plan
This part must be completed by your financial institution or eligible employer plan
if all or part of your benefit is made payable to an IRA or eligible employer plan.
Name and address of financial institution or eligible employer plan

Account number

Certification: As a representative of the financial institution or employer plan named above, I confirm the account number for the individual named above
and the address of this financial institution or plan. I certify that the financial institution or plan agrees to accept funds as a direct trustee-to-trustee transfer
from the Office of Personnel Management, to deposit them in an eligible IRA or employer plan as defined in the Internal Revenue Code and to account for
these monies in compliance with the Internal Revenue Code.
Signature of certifying representative

Typed or printed name of certifying representative

Telephone number (including area code)

Date (mm/dd/yyyy)

Certification by Financial Institution or Eligible Employer Plan
This part must be completed by your financial institution or eligible employer plan
if all or part of your benefit is made payable to an IRA or eligible employer plan.
Name and address of financial institution or eligible employer plan

Account number

Certification: As a representative of the financial institution or employer plan named above, I confirm the account number for the individual named above
and the address of this financial institution or plan. I certify that the financial institution or plan agrees to accept funds as a direct trustee-to-trustee transfer
from the Office of Personnel Management, to deposit them in an eligible IRA or employer plan as defined in the Internal Revenue Code and to account for
these monies in compliance with the Internal Revenue Code.
Signature of certifying representative

Typed or printed name of certifying representative

Telephone number (including area code)

Date (mm/dd/yyyy)

16
Previous editions are not usable.

Standard Form 3104B
Revised July 2020

Section 6 - Agency Information and Certifications
Name of deceased employee (last, first, middle initial)

Date of birth (mm/dd/yyyy)

Social security number

A. Employing Office: To be completed by office maintaining Official Personnel Folder (OPF)
Part 1 - General Information
1. Retirement system coverage (check applicable box)
Federal Employees Retirement System (FERS) - Automatically covered by FERS
effective January 1, 1987, or upon employment

2. Type of death benefit which appears payable
(check all that apply)
Monthly survivor annuity
Basic Employee Death Benefit Lump Sum

FERS - Elected to transfer to FERS. Effective date of election: _____________________
Civil Service Retirement System (CSRS) - Use SF 2800 in lieu of this form.
Other - Explain. __________________________________________________________

Payment of retirement contributions

Part 2 - Federal Employee's Compensation Information
1. Did the deceased employee ever apply for or receive benefits from the Office of Workers' Compensation Programs (OWCP), Department of Labor, because
of a job-related illness or injury?
Yes, complete 1a thru 3 below
a. Compensation claim number

No, go to Part 3 below
b. Benefit received
From (mm/dd/yyyy) To (mm/dd/yyyy)
Scheduled award

c. Type of benefit

Total or partial disability

Scheduled award
Total or partial disability
2. If the deceased employee applied for workers' compensation (other than as listed in item 1a above) but did not receive benefits, check reason below and
give the requested information.
a. Compensation claim number
b. Date claim denied (mm/dd/yyyy)
Claim denied (enter date of denial in item 2b)
Awaiting OWCP decision
3. Except for scheduled compensation awards, workers' compensation survivor benefits and FERS survivor benefits cannot be paid for the same period
of time. Please complete information below.
a. Did the above employee's death occur due to a work-related injury or illness?
No, go to Part 3
Yes, complete 3b - e below
b. Has a claim for workers' compensation based on this death been filed?
Yes

No, go to Part 3
d. Compensation claim number

c. Name of person filing for workers' compensation

►

Awaiting OWCP decision

e. Date claim denied (mm/dd/yyyy)

Claim denied
►
Part 3 - Federal Employee's Health Benefits and Group Life Insurance Information
1. Was the deceased employee enrolled in the Federal Employees Health Benefits Program?
Yes, complete 1a-c below
a. Enrollment code

No, go to item 2
b. Does a survivor appear eligible for a monthly annuity?

Yes, go to item 2
c. Is there a surviving spouse eligible for the Basic Employee Death Benefit?

No, go to item 1c

No, go to item 2
Yes, complete SF 3104B, Section 3, Page 6
2. Did the deceased employee have Federal Employees' Group Life Insurance Coverage?
No, go to Part 4
Yes, go to items 2a - 2c
a. When was the life insurance certified to the Office of Federal Employees' b. What was the amount of basic annual pay certified?
Group Life Insurance (OFEGLI)?
c. What life insurance options did the deceased carry?
Option A

Option B

Option C

17

No optional coverage(s)

Standard Form 3104B
Revised July 2020

Part 4 - Checklist
Form number

Document title

Requirement

Attached
Yes

SF 3104

Application for Death Benefits

Required in all cases

SF 2809s

Employee Health Benefits Election Form

Required in all cases

SF 2810s

Notice of Change in Health Benefits Enrollment

Required in all cases, unless not covered
under FEHB plan

DD 214

Military Discharge

Recommended in all cases with military service

SF 3104B Section 1

Certified Summary of Federal Service

Required in all cases

SF 3104B Section 2

Basic Employee Death Benefit (BEDB)

Recommended in all cases where a Basic
Employee Death Benefit is payable

SF 3104B Section 3

Health Benefits Election

Required in all cases where a Basic Employee
Death Benefit is payable and a survivor annuity
is not payable

SF 3104B Section 4

Information and Elections Regarding Post-1956
Military Service

Required in all cases with military service after
12/31/56 for which employee did not complete
deposit and a survivor annuity payable

SF 3104B Section 5

Rollover Option Information for Lump Sum
Benefits Payable to a Surviving Spouse or
Surviving Former Spouse

None

Death Certificate

Required in cases with Basic Employee Death
Benefit or if employee contributions, excess
retirement deductions or voluntary contributions
are payable to the surviving spouse/former
spouse. If not completed, payment may be
delayted.
Certified copy required in all cases

None

Marriage Certificate

Required for all married employees

None

Children's birth certificates

Required for all minor or student children

None

Medical documentation (disabled children)

Required for all disabled children

None

Adoption papers

Required if applicant is an adopted child

None

Guardianship papers

Required if a court appointed guardian is
established for eligible children

None

Court appointment documents for executor/
administrator of estate

Required if court appointed administrator/executor
has been appointed and no annuity is payable

None

Social Security Number(s) for all applicants

Required in all cases

N/A

Sent to
OWCP

18
Standard Form 3104B
Revised July 2020

Part 5 - Certification by Personnel Officer (or Designee)
I certify that the above accurately reflects verified information in official records.
1. Signature

2. Date (mm/dd/yyyy)

3. Address

4. Official title
5. Telephone number (including area code)

6. Person to contact for further information (print or type)

7. Fax number (including area code)

8. E-mail address (if applicable)

B. Payroll Office Checklist
1. Is deceased employee's sick leave balance shown on SF 3100?

2. If deceased employee worked an irregular tour of duty (or exceeded his/her
regular, part-time tour), are earnings for last 52 weeks shown?

No, explain in item 7.
Yes
3. Is deceased employee's health benefits status posted on SF 3100?

Yes
No, explain in item 7.
4. If a former spouse of the deceased employee was making direct health
benefit premium payments to your payroll office, has the SF 3100 been
properly annotated?

No, explain in item 7.
Yes
5. Has the SF 3100 been properly annotated concerning deposit for
post-1956 military service?

Not applicable
6. Disposition of SF 3100
SF 3100 and SF 3103
are attached

Yes
Forwarded to:

No, explain in item 7.

Yes

No, explain in item 7.

Date of SF 3103
(mm/dd/yyyy)

Date of SF 3103
(mm/dd/yyyy)

SF 3100 was mailed ►
7. Remarks

Certification by Payroll Officer (or Designee)
I certify that the above accurately reflects official records maintained by this office.
8. Signature

10. Address

9. Date (mm/dd/yyyy)

11. Official title

12. Telephone number (including area code)

13. Person to contact for further information (print or type)

14. Fax number (including area code)

15. E-mail address (if applicable)

19

Standard Form 3104B
Revised July 2020