**Designation of a Recipient of the Death Gratuity Payment under**

**Section 1105 of Public Law 110-181**

  ----------------------- ----------------------- -----------------------
  Name (Last, First,      Date of Birth           Social Security Number
  Middle)                                         

  Department or Agency in                         Location (City, State,
  which presently                                 and ZIP code)
  employed (include                               
  Bureau, Division, and                           
  phone number)                                   
  ----------------------- ----------------------- -----------------------

If you have no surviving spouse or child eligible to receive the death
gratuity, and you wish to designate any one or more of your parents or
brothers or sisters to receive specific shares of the gratuity, please
fill in the required boxes below. If you designate more than one
individual and do not indicate a share for each individual, the death
gratuity will be paid to those individuals in equal shares. **An
individual designated below must be living at the time of payment to
receive any or all of your death gratuity**.

  ------------------------ ------------------------ -------------- ----------
  First Name, middle       Address (including ZIP   Relationship   Share to
  initial, and last name   code) of each designee   to you (must   be
  of each designee                                  be parent,     provided
                                                    brother, or    to each
                                                    sister)        designee

                                                                   

                                                                   

                                                                   

                                                                   
  ------------------------ ------------------------ -------------- ----------

In addition to or instead of the above, you may designate any person or
persons to receive up to 50% of your death gratuity. If you do not
designate anyone in this section, 100% of the death gratuity will be
disbursed according to the order of precedence described in the
instructions. Under this provision, you may designate a maximum of 50%
of the death gratuity in 10% increments. If you utilize this designation
provision, the undesignated portion of the death gratuity will be
disbursed as specified in the order of precedence. **An individual
designated below must be living at the time of payment to receive any of
your death gratuity.**

  ----------------------------- ----------------------------- -------------
  First Name, middle initial,   Address (including ZIP code)  Share to be
  and last name of each         of each designee              provided to
  designee                                                    each designee
                                                              (must be in
                                                              10%
                                                              increments)

                                                              

                                                              

                                                              

                                                              

                                                              
  ----------------------------- ----------------------------- -------------

I understand that if this Designation is not valid unless delivered to
an official of the employing establishment prior to the death of the
employee and that it will stay in effect unless it is cancelled.

I understand that if this Designation is invalid for any reason, the
death gratuity will be paid according to the next most recent valid
designation. In the event no designation has been made, the death
gratuity will pay according to the order of precedence in section 1105
of Public Law 110-181 as described in the instructions.

I am canceling any and all previous Designations of the death gratuity
payment under Public Law 110-181, section 1105, and am now designating
the recipients named above.

  ----------------------------------------------------- -----------------
  Signature of the Federal Employee. **This form is not Date (mm/dd/yyyy)
  valid unless the employee signs in this box and       
  enters a date in the box to the right.**              

  ----------------------------------------------------- -----------------

I have received this form from the federal employee who has signed
above. To the best of my knowledge and belief, the employee has filled
out this form completely in accordance with the instructions on the
form.

+-----------------------------------------------------+----------------+
| Signature of the Employing Establishment Official.  | Date           |
| **This form is not valid unless, [prior to the      | (mm/dd/yyyy)   |
| death of the employee]{.underline}, the official    |                |
| signs in this box and enters a date in the box to   |                |
| the right.**                                        |                |
+-----------------------------------------------------+----------------+
| Printed Name, Title, Address and phone and fax      |                |
| numbers of the Employing Establishment Official.    |                |
|                                                     |                |
| NAME:                                               |                |
|                                                     |                |
| TITLE:                                              |                |
|                                                     |                |
| ADDRESS:                                            |                |
|                                                     |                |
| PHONE NUMBER:                                       |                |
|                                                     |                |
| FAX NUMBER:                                         |                |
+-----------------------------------------------------+----------------+

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a),
you are hereby notified that: (1) The Federal Employees' Compensation
Act (FECA), as amended and extended (5 U.S.C. 8101, et seq.) including
the Death Gratuity in section 1105 of Public Law 110-181 is administered
by the Office of Workers\' Compensation Programs of the U.S. Department
of Labor, which receives and maintains personal information on claimants
and their immediate families. (2) Information which the Office has will
be used to determine eligibility for and the amount of benefits payable
under the FECA, and may be verified through computer matches or other
appropriate means. (3) Information may be given to the Federal agency
which employed the claimant at the time of injury in order to verify
statements made, answer questions concerning the status of the claim,
verify billing, and to consider issues relating to entitlement to
benefits or other relevant matters. (4) Information may be given to
Federal, state and local agencies for law enforcement purposes, to
obtain information relevant to a decision under the FECA, to determine
whether benefits are being paid properly, including whether prohibited
dual payments are being made, and, where appropriate, to pursue
salary/administrative offset and debt collection actions required or
permitted by the FECA and/or the Debt Collection Act. (5) Disclosure of
the claimant\'s social security number (SSN) or tax identifying number
(TIN) on this form is mandatory. The SSN (and/or TIN), and other
information maintained by the Office, may be used for identification, to
support debt collection efforts carried on by the Federal government,
and for other purposes required or authorized by law. (6) Failure to
disclose all requested information may delay the processing of the claim
or the payment of benefits, or may result in an unfavorable decision or
reduced level of benefits.

**Note: This notice applies to all forms requesting information that you
might receive from the Office in connection with the processing and
adjudication of the claim you filed under the FECA.**

**Designation of a Recipient of the Death Gratuity Payment under**

**Section 1105 of Public Law 110-181**

**INSTRUCTIONS**

If a federal civilian employee or an employee of a nonappropriated fund
instrumentality dies of injuries incurred in connection with his or her
service with an Armed Force in a contingency operation, his or her
eligible survivors may receive a death gratuity payment of up to
\$100,000. The gratuity is a one-time payment disbursed to the highest
ranked survivor or survivors of the employee according to the order of
precedence below.

**You do not need to fill out this form if you are satisfied that 100%
of the gratuity will be paid entirely to the survivor highest on the
list below:**

1.  Your surviving spouse.

2.  If you do not have a surviving spouse, your death gratuity will be
    paid to your children, in equal shares. Your children include any
    adopted children, stepchildren who are part of your household at the
    time of death, and any illegitimate children, subject to the
    following limitation. An illegitimate child of a male decedent only
    qualifies as an eligible survivor if the child:

    -   has been acknowledged in writing signed by the decedent;

    -   has been judicially determined, before the decedent\'s death, to
        be his child;

    -   has been otherwise proved, by evidence satisfactory to the
        employing agency, to be a child of the decedent; or

    -   is a child to whose support the decedent had been judicially
        ordered to contribute.

3.  If you have no surviving spouse or eligible child, you can choose to
    divide your death gratuity among your parents or brothers or
    sisters, as you designate in section B of the form.

    -   The term "parents" includes adoptive parents and persons who
        stood in loco parentis to the decedent for not less than one
        year before the decedent became an employee covered by this
        provision, but the term is limited to one father or mother or
        their counterparts.

    -   "Brothers" and "sisters" include half-brothers and half-sisters,
        and brothers and sisters through adoption.

4.  If you have no surviving spouse or eligible child and do not
    designate anyone in section B of the form, your death gratuity will
    be paid to your living parent or parents, in equal shares.

5.  If you have no surviving spouse, eligible child, or living parent
    and do not designate anyone in section B of the form, your death
    gratuity will be paid to your brothers and sisters, in equal shares.