Death Gratuity Information Sheet

CBP Privacy Office
Death Gratuity Information Sheet
Privacy Act Statement/e(3) Notice

CBP Death Gratuity Information Sheet Privacy Act Statement
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of the
information collection on this website.
AUTHORITY:
U.S. Customs and Border Protection (CBP) is authorized to collect the information requested on
this form in in accordance with Section 651 of Public Law (P.L.) 104-208, the Omnibus
Consolidated Appropriations Act, effective September 30, 1996.
PURPOSE:
CBP will collect this information to determine if death gratuity is payable to a personal
representative or beneficiary when there is clear and convincing evidence that a CBP employee
dies from an injury or illness sustained in the line of duty, which occurred on or after August 2,
1990. These records are primarily used to document the processing and adjudication of claims
concerning the settlement of the account for a deceased Federal law enforcement or civilian
employee.
ROUTINE USES:
The information requested on this form may be shared with appropriate agencies, entities, and
persons within CBP and the U.S. Department of Agriculture to process the death gratuity
payment. A complete list of the routine uses can be found in the system of records notice
associated with this information collection, “U.S. Office of Personnel Management OPM\Govt-9
File on Position Classification Appeals, Job Grading Appeals, Retained Grade or Pay Appeals,
Fair Labor Standard Act Claims and Complaints, Federal civilian employee Compensation and
Leave claims, and Settlement of Accounts for Deceased Civilian Officers and Employees.” The
full list of system of records notices can be found on the Department of Homeland Security's
website at http://www.dhs.gov/system-records-notices-sorns.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:
Providing this information to CBP is considered voluntary. However, providing information will
allow individuals to gain further information and will avoid a delay in processing CBP death
gratuity benefits.

PAS/e(3)
Version 03-2018

Page 1

1651-0NEW
DEATH GRATUITY INFORMATION SHEET
Name of Deceased CBP Employee:
Date of Death:

Location of Death (State):

Name of Claimant:
Address:
Phone:
Email:

Preferred Mode of Communication:_____________
Preferred Mode of Communication:_____________

Relationship to Employee (identify as applicable):
Spouse
Domestic Partner
Personal Representative (aka
Executor/Administrator of Estate)
Parent (specify mother or father)
Sibling
Other (pls specify)

Date of Marriage:
Date of Registration:
Date of Appointment:

Yes

Did the Employee have children (biological or legally adopted):
Ages:
Claimant is also the parent:
If Claimant is not the parent, please identify other parent:
Did the Employee have an executed Will:
Name:
Contact Information (if known):

Yes

No

No

If yes, identify the named executor.

Has a petition for probate or for administration of the employee’s estate been or will be filed with
the state court?
Yes
No
If yes, please indicate:
State:
Date of Filing:
Requested Documents (as applicable)
Death Certificate
Marriage Certificate
Executed Will (if applicable). Only include 1st page, signature page, and page identifying executor.
Letter of Probate/Administration (if applicable)
I hereby certify that the information I am providing is true and accurate to the best of my knowledge and
understand that it will be used to identify the appropriate individual that is or could be designated the personal
representative of the employee’s estate in accordance with the Death Gratuity payments as authorized under
Section 651 of Public Law 104-208, the Omnibus Consolidated Appropriations Act effective September 30,
1996.

Signature

Date

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to
respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this
collection is 1651-0NEW The estimated average time to complete this application is 15 minutes. If you have any comments regarding the
burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 90K Street, NE., Washington DC
20229.