Application for Death Benefits 

Civil Service Retirement System Civil Service 

Retirement System 

This application is for use by persons applying for benefits which may be payable under the Civil Service Retirement System (CSRS) 

because of the death of an employee, former employee, or retiree who was covered by CSRS at the time of his/her death or separation from 

Federal service. You should have received an informational pamphlet entitled “Applying for Death Benefits Under the Civil Service 

Retirement System” SF 2800-1, with this application. If you did not receive the pamphlet and the deceased was a Federal employee at the 

time of his/her death, you should get a copy from the deceased’s employing agency. If the deceased was retired or a former employee not 

yet receiving a retirement benefit, you should get a copy from the Office of Personnel Management (OPM). You can write to the Office of 

Personnel Management at OPM, P.O. Box 45, Boyers, PA 16017-0045, call OPM’s Retirement Information Office at 1-888-767-6738, or send 

us email at retire@opm.gov. 

If the deceased was an employee at the time of death, send your completed application, with any 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 the 

Office of Personnel Management, P.O. Box 45, Boyers, PA 16017-0045. 

If your address changes before we give you a survivor annuity claim number, notify us in writing and give 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, notify us of the change by calling or writing as described above. Be sure to refer to your claim number. 

Instructions For Completing Application Section B - Information About the Applicant

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 (?). 

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 The following additional information should help you to you; we will not pay you based on a will or other docu- answer those questions on the application which are not ment prepared by the deceased.) entirely self-explanatory.

Section C - Information About the Deceased Section A - Information About the Deceased Person’s Spouse 6.	 If deceased had ever applied for or received retirement

benefits, show the retirement claim number. 1. Attach a copy of your marriage certificate.

7. Recurring payments from the Office of Workers’

Compensation Programs, U.S. Department of Labor

(OWCP) and CSRS survivor annuity benefits usually are

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”.

not payable for the same period of time. If the deceased If you were not married by someone empowered by the

had applied for or received benefits from the OWCP State to perform marriages, check “Other” and explain

based on an illness or injury received resulting from a

condition of employment within the last two years,

indicate here. The OWCP claim number appears on the

(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

U.S. Treasury checks and correspondence from OWCP. court order or judgment. If you do not have a court order

8. See the pamphlet entitled “Applying for Death Benefits or judgment, attach two notarized affidavits from persons

Under the Civil Service Retirement System” to help you who are in a position to know the facts and clearly state:

(1) the relationship between you, your spouse, and the determine which block to check.

person swearing to the affidavit; (2) the length of time 10. If the deceased had no former marriage, write “none.”

Attach copies of death certificates and complete copies of

court orders of divorce or annulment if these occurred on

or after May 7, 1985. If you are the spouse of the

deceased and you and the deceased were married more

than one time, be sure to show the date your prior

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 marriage(s) ended.

Office of Personnel Management 

CSRS/FERS Handbook for Personnel Standard Form 2800

and Payroll Offices The June 2006 edition is usable. Rev. December 2008
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.

In addition, your own affidavit is required. It should state:

(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 that ended it); and (3) any other facts 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, income tax returns, etc.

2. If you married the deceased more than once, give dates

that each marriage began and ended.

Section E - Information About the Deceased

Person’s Dependent Children

1. a. 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:

• 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 and unmarried, but who became

mentally and/or physically disabled before age 18 and

who, because of the disability, is incapable of selfsupport.

• is between ages 18 and 22, unmarried, and a full-time

student in a recognized educational institution.

b. Attach a copy of the birth certificate for each child for

whom you are applying.

d. 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.

e. If the unmarried dependent son or daughter is 18 or over,

state whether he or she is a full-time student and/or

disabled. Adult children may submit separate applications

if they want separate payments made to them.

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.

3.d. 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.

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);

• 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. The

people you list must be blood kin of 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 is not appointed by a court,

check “no.” If you have been appointed by a court, attach

a copy of the court appointment.

Section H - Active Military Service

You do not need to complete parts 1 and 2 of this section if the

deceased was retired at the time of death, since OPM already

has this information.

1. 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

service 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 and during an

initial (3 months or longer) training period. However,

Standard Form 2800

 Rev. December 2008
full-time National Guard duty 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 you have a copy of the deceased person’s DD 214s or 

other discharge certificate(s) showing the dates of active 

duty and the deceased was an employee at the time of 

death, you should attach it (them) to your application. 

2. Persons who performed active military service after 

December 31, 1956, must pay or have paid a deposit to 

receive credit 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 SF 2800A, which 

can be obtained from the agency where the deceased was 

last employed. The agency can provide you with more 

information about this deposit. 

3. 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. 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 title 10, U.S. Code 

Sections 12731 through 12739, (formerly Chapter 67, 

title 10) (reserve retired pay at age 60 based on 20 years 

of active and reserve service), no such reduction is 

required. You should attach a copy of your award of 

military survivor benefits to show that the award was 

based on one of the above reasons. 

Section J - Certification

1. Sign your name in ink. Please note that OPM will not

accept the signature of someone who has a power of attorney for the applicant named in Section B. A courtappointed fiduciary can apply on behalf of the applicant,

provided a court-certified copy of the court appointment is

attached to the application for death benefits. If there is

no court-appointed fiduciary and the applicant is not competent, a relative or person responsible for the applicant

may sign. OPM will arrange later for the appointment of

a representative payee for the person named in Section B.

Section K - Applicant’s Checklist

Use this section of the application to ensure that all required 

supporting documentation is attached. 

SF 2800A

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 Standard Form 

2800A, which can be obtained from the deceased person’s 

employing agency. Instructions for completing SF 2800A 

are contained on the form itself. 

Privacy Act Statement

Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code). 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. 

The information may be shared and is subject to verification, via paper, electronic media, or through the use of computer 

matching programs, with national, state, local or other charitable or Social Security administrative agencies 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. It may also be shared and verified, as noted above, with law enforcement 

agencies when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 

22, 1943) authorizes the use of the Social Security Number. Failure to furnish the requested information may delay or prevent 

action on your application. 

Public Burden Statement

We think this form takes an average of 45 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), 

CRIS Publications Team, (3206-0156), Washington, D.C. 20415-3430. Completed application forms should not be sent to this 

address. The OMB Number 3206-0156, is currently valid. OPM may not collect this information, and you are not required to 

respond, unless this number is displayed.

 Standard Form 2800

 Rev. December 2008
Civil Service 

Retirement System 

Form Approved 

Application for Death Benefits OMB No. 3206-0156

Civil Service Retirement System

Section A - Information About the Deceased 

1. Full name of 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 (such as 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? No Yes

7b. OWCP claim number

8. What was deceased person's employment status at time of death (see pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System")

Employee Complete SF 2800A, which can be obtained from the deceased person's former employing agency. Former employee Retiree

9. Name of deceased person's spouse at time of death (if not married at time of death write "none")

10a. Name of deceased person's spouses from all former marriages 10b. How did each marriage end? 10c. Date each marriage ended

Death

Divorce/annulment A court has awarded this

former spouse a survivor

benefit.

A court has awarded this

former spouse a survivor Death benefit.

Divorce/annulment

Section B - Information About the Applicant

1. Your full name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number

4a. Are you a citizen of the United States of America?

Yes No

4b. What country are you a citizen of?

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

Former spouse Complete Section D below

Executor or administrator of estate (attach copy of court order)

Child (or descendant of deceased child or guardian of minor or disabled child)

Designated beneficiary (attach copy of designation, if available)

Widow(er) Complete Section C below

Parent of decedent (Each parent should complete a separate application. If one 

parent is deceased, attach a copy of the death certificate.)

Other (specify):

6. Did you cash any check(s) issued to the deceased after the date of death or did you withdraw from the deceased's savings or checking account retirement monies paid by

direct deposit after the date of death?

No Yes Any uncashed checks must be returned to the Treasury.

Section C - Information About the Deceased Person's Spouse

(Complete if you are the widow(er).)

1. Marriage performed by

Clergy/Justice of Peace Other (explain)

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

3a. Have you remarried after your spouse died?

No Yes

3b. Date of remarriage (mm/dd/yyyy)

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 (for example, Civil Service, Foreign Service) 4e. Claim number (assigned to you by

retirement system in item 4d.)

Office of Personnel Management 

CSRS/FERS Handbook for Personnel Standard Form 2800

and Payroll Offices Page 1 of 4 Rev. December 2008 
(child of former

marriage, adopted, etc.)

3.

2.

(mm/dd/yyyy)

unmarried

1e. Age 18

or over

2.

Yes, attached No

No Yes

first

(mm/dd/yyyy)

(mm/dd/yyyy)

Disabled

6.

Yes

1c.

(mm/dd/yyyy)

1f. Child's Social 

Security Number

Student

Other

Legal guardian

3b. child

No Yes

No Yes

No

Yes When born, send birth certificate for child to OPM No

No Yes

Specify

Other

Legal guardian

Specify

Other

Legal guardian

Specify

3c. Name(s) of children

1d. Child's relationship to deceased

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

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

Is there a child of the deceased not yet born?

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 A.1?

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

1a. Date of marriage to the deceased

1a. Are there any dependent children as defined in the instructions? 

Is there a court order awarding you any portion of the deceased person's CSRS retirement or survivor benefits?

Section D - Information About the Deceased Person's Former Spouse

(Complete if you are a former spouse.)

Yes, on record at OPM

5b. Name of deceased former spouse

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

4b. Date of marriage after marriage to deceased ended

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

1b. Date of divorce or annulment from the deceased

5c. Date of birth

Section E - Information About the Deceased Person's Dependent Children

If you checked "Employee" in Section A.8, your former spouse performed more than 18 months of creditable civilian Federal service, you were married to the deceased

for at least 9 months, and a court awarded you all or a portion of the survivor annuity, contact the deceased person's employing agency in order to complete the

necessary election in Standard Form 2800A.

1b. Name(s) of unmarried dependent children Date of birth

(list in order of birth)

3a. Do you (the applicant) have responsibility for all the children in Section E.1?

Name and address of person having responsibility for child

3d. Custodian's Relationship to

Go to item 4a Go to item 3b

Go to item 5a Go to item 4b

Go to item 6 Complete items 5b-5e below

Complete items 1b-1f below Go to Section F

Complete items 3b-3d below 

Standard Form 2800 

Page 2 of 4 Rev. December 2008
3.

1.

settle the estate of the deceased?

employing agency. 

2.

1.

2.

1. 2. Complete address 3.

Yes

Yes No

1.

From To

(Attach verification 

4. Social Security

age 4.)

No

Yes No Don't know

Yes No Don't know

Yes No Don't know

Yes No

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

All spouses and former spouses complete 3a-3c.

3a. Was the deceased receiving military retired pay at the time of death?

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

Has an executor, administrator or other official been appointed by the court to

Complete if deceased was an employee at time of death. Also, complete and attach Standard Form 2800A which can be obtained from the deceased person's

If any of the above listed service was performed after 12/31/56, was a deposit

made to the Retirement Fund for the service?

Public Law 104-134 requires that most Federal payments on or after July 26, 1996, be paid by direct deposit into a savings or checking account at a financial institution.

However, if receiving your payment electronically would cause you a hardship because it would cost you more than receiving your payment by check or you have a

disability or geographic, language or literacy barrier, you may receive your payment by check. Therefore, you must select one of the following:

Section H - Active Military Service (Complete ONLY if you are the surviving spouse or former spouse)

Full name and address of person appointed

Section F - Information About Other Heirs

List other relatives who can inherit from the deceased as explained in the instructions. Do the best you can without delaying your application. 

Full name of relative

Section G - Information About the Deceased Person's Estate

Relationship to deceased 

Go to item 3 below

Complete if deceased was an employee at time of death. Do not complete if the deceased was retired at the time of death, since OPM already has this information.

If the deceased performed active, honorable service in the Armed Forces or other uniformed service as described in the instructions, complete all items below and attach a

copy of the discharge certificate or other certificate of active military service (if available).

1a. Branch of service

1b. Dates of active duty

3c. Are you eligible for military survivor benefits?

of your eligibility/ineligibility for such benefits.)

Number if known

Section I - Direct Deposit

Please send my annuity payments directly to my checking or savings account. (Go to item 2 on p

Please pay me by check. I have a hardship as described above. (Go to Section J.)

My permanent payment address is outside the United States in a country not accessible via direct deposit. (Go to Section J.) 

Standard Form 2800

Page 3 of 4 Rev. December 2008
Remarks

5.

2.

? 

Attached

(Continued)

3.

4.

verify this number.)

7.

8.

Checking Savings

Special note:

6. Account number

Note:

1. (Sign in ink; do not print.) 

2. Mailing address

3. 4. Date (mm/dd/yyyy)

Warning:

(18 USC 1001)

Required in all cases.

Document Title Comments

Death certificate

Marriage certificate 

or proof

Child(ren)'s birth

certificate(s)

are required.

you

Court papers

appointing

executor/administrator

Court papers

other fiduciary

military discharge

certificates

divorce/annulment

( ) 

Yes No N/A

Yes No

Yes No

What kind of account is this?

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)

Section I - Direct Deposit

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?

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

Name and address of your financial institution

Telephone number of your financial institution (including area code)

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. 

We cannot process your application if you do not complete all of Section J.

Signature of applicant named in Section B. Daytime telephone number

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.

Best time to call you

Section K - Applicant's Checklist

Attach copies of the following documents to expedite the processing of your application.

Required if you were spouse of deceased at time of death (if married more than once, 

provide copies of all certificates). Affidavits or other proofs of common law marriage

Recommended for all children for whom are applying for benefits.

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

appointing guardian or

Required for minor or disabled children who have a court-appointed fiduciary.

Required for any incompetent applicant who has a fiduciary.

DD 214s or other Provide if you are applying as surviving spouse or former spouse and the deceased was

an employee at time of death. Failure to attach the information may delay the

processing of your claim.

Court order of Required from former spouse if not already on record at OPM.

Needed from other applicants if available.

Standard Form 2800 

Page 4 of 4 Rev. December 2008