Application for Death Benefits 

Federal Employees Retirement System 

Standard Form 3104 

Previous editions are not usable. Revised August 2002

OMB number 3206-0172

Form approved: 

This application is for use by persons applying for benefits which may be payable under the Federal Employees Retirement System (FERS) 

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

Federal service. You should have received an informational pamphlet entitled, Applying for Death Benefits Under the Federal Employees 

Retirement System, SF 3114 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 either write to the Office 

of Personnel Management at OPM, FERS, P.O. Box 45, Boyers, PA 16017-0045 or call OPM's Retirement Information Office at 

1-888-767-6738. Customers within local calling distance to Washington, DC must contact OPM on 202-606-0500. You can also request 

SF 3114 over the Internet at www.opm.gov/retire/html/library/fers.html. 

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

office in the agency where the deceased was last employed. If the deceased was a former employee or annuitant at the time of death, send it 

to the Office of Personnel Management, Federal Employees Retirement System, P.O. Box 45, Boyers, PA 16017-0045. 

If your address changes before you receive your claim number, write to OPM, giving your name, date of birth, your Social Security 

Number, and the deceased person's name, date of birth and Social Security Number. If you have received your claim number, please refer 

to it. 

Instructions For Completing Application 

Type or print clearly in ink. If you need more space in any 

section, use a plain piece of paper with your name, date of birth, 

and Social Security Number, and the deceased person's name, 

date of birth and Social Security Number, written at the top. If 

you do not know an answer, write "unknown." If you are unsure 

of information (for example, if you do not know an exact date), 

answer to the best of your ability, followed by a question mark 

(?). 

The following additional information should help you to answer 

those questions on the application which are not entirely 

self-explanatory. 

Section A - Information About the Deceased 

6. If deceased had ever applied for or received retirement benefits, show the CSA number (retirement claim 

number). 

7. Recurring payments from the Office of Workers' 

Compensation Programs, U.S. Department of Labor 

(OWCP) and FERS survivor annuity benefits and/or 

the FERS Basic Employee Death Benefit usually are 

not payable for the same period of time. If the 

deceased had applied for or received benefits from 

the OWCP based on an illness or injury resulting 

from a condition of employment within the last two 

years, indicate here. The OWCP claim number 

appears on the U.S. Treasury checks and correspondence from OWCP. 

8. See the pamphlet entitled, A pplying for D eath 

B enefits U nder the F ed eal E mployees R e tirement 

System, SF 3114 to help you determine which block 

to check. 

10. If the deceased had no former marriage(s), write 

"none." Attach copies of death certificates, divorce 

decrees from former marriage(s) or annulment(s). If you 

are the spouse of the deceased and were married to the 

deceased before, be sure to show the date your prior 

marriage(s) ended. 

Section B - Information About the Applicant 

5. If you checked "Designated beneficiary" and have a 

copy of the form designating you as beneficiary, 

attach it to the application. If you checked "Parent," 

both parents must submit completed applications. If 

one is deceased, attach a copy of the death certificate. Otherwise, provide name and address of other 

parent in Section F, if known. If you checked "executor or administrator of estate," attach a copy of the 

court order appointing you executor or administrator. 

(Note that a court must have appointed you; we will 

not pay you based on a will or other document 

prepared by the deceased.) 

Section C - Information About the Deceased 

Person's Spouse 

1. Attach a copy of your marriage certificate. 

If you were married by a priest, rabbi, pastor, Justice 

of the Peace or other person empowered by the 

State to perform marriages, check "Clergy/Justice of 

the Peace". If you were not married by someone 

empowered by the State to perform marriages, check 

"Other" and explain (for example, "common law" or 

"tribal marriage"). 

If marriage is common law and a State court has 

determined that you were married, send a copy of 

the court order or judgment. If you do not have a 

court order or judgment, attach two notarized affidavits from persons who are in a position to know the 

facts which clearly show: (1) the relationship 

Office of Personnel Management 

CSRS/FERS Handbook for Personnel NSN 7540-01-249-5573 

and Payroll Offices 3104-106 
between you, your spouse, and the person swearing 

to the affidavit; (2) the length of time you and the 

deceased lived together; (3) the address or 

addresses at which you resided while you lived 

together; (4) whether there was any public 

announcement in connection with your common law 

marriage; (5) whether you and the deceased were 

regarded among your neighbors, friends, and 

relatives as being husband and wife during the time 

you lived together; and (6) how the person swearing 

to the affidavit is in a position to know the facts being 

presented in the affidavit. 

In addition, your own affidavit is required. It should 

show: (1) the date on which, and the State in which, 

you and your spouse mutually agreed to become 

husband and wife; (2) whether you or your spouse 

were ever married, ceremonially or under common 

law, to anyone else before entering into the common 

law relationship (if so, state in your affidavit all the 

facts of each previous marriage, including the date it 

took place and the date of the death or divorce which 

ended it); and (3) any other facts which you believe 

will help prove you were husband and wife. You may 

also submit other documents which show a husband 

and wife relationship such as a naturalization certificate, deeds, immigration records, insurance policies, passports, child's birth certificate, etc. 

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 parentchild relationship, and/or 

4. recognized child born out of wedlock if there 

was a judicial determination of support or if 

the deceased made regular and substantial 

contributions for the support of the child. 

• is age 18 or older, but who became mentally 

and/or physically disabled before age 18 and who, 

because of the disability, is incapable of selfsupport. Attach a copy of the Social Security 

Administration's determination of disability (prior 

to age 18) for disabled child(ren) over age 18. 

• is between ages 18 and 22 and who is unmarried 

and a full-time student in school. 

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. 

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. 

4. You must apply for benefits from the Social Security 

Administration (SSA) for minor or disabled children 

of the deceased. Federal Employees Retirement 

System (FERS) benefits to children will not be paid 

until we have received verification of their entitlement 

to (and amount of) or lack of entitlement to SSA 

benefits. You should submit a copy of SSA's notice of 

award or denial with this application, if available. If it is 

not submitted, we will obtain the information from SSA, 

however, this may delay the processing of your claim. 

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. 
Section G - Information About the Deceased 

Person's Estate 

1. If someone was named as executor or administrator 

in the deceased person's will, but hasn't been 

appointed by the 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 the Office of 

Personnel Management (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, 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 the deceased 

was a retiree, OPM already has information about 

his/her military service. 

If you have a copy of the deceased person's DD 214's 

or other discharge certificate(s) showing the dates of 

active duty and the deceased was a former employee 

at the time of death, you should attach it (them) to 

your application. 

2. Persons who performed active military service after 

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

to receive credit under the Federal Employees Retirement System (FERS) for the military service. 

If the deceased was an employee at the time of death, 

you may pay or complete the payment of the deposit 

by completing the election form contained in Documentation and Elections in Support of Application for Death 

Benefits when Deceased was an Employee at the Time of 

Death, Standard Form (SF) 3104B, which can be obtained 

from the agency where the deceased was last employed. 

The deceased's agency can provide you with more information regarding this deposit. 

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 Chapter 67, Title 10, 

(formerly title III) of Public Law 80-810 (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 verifying the award was based on one of the above reasons. 

Section K - Applicant's Checklist 

Use this section of the application to ensure that all required 

supporting documentation is attached. 

SF 3104A 

If the deceased was a retiree at the time of death and you are the 

surviving spouse, you should complete Survivor Supplement 

(FERS), SF 3104A, which is attached to this application. 

Instructions for completing SF 3104A are contained on the form 

itself. 

SF 3104B 

If the deceased was an employee at the time of death and you 

are the surviving spouse or former spouse, you and the deceased 

person's agency should complete Documentation and Elections 

in Support of Application for Death Benefits when Deceased 

was an Employee at the Time of Death, SF 3104B, which can be 

obtained from the deceased person's former employing agency. 

Instructions for completing SF 3104B are contained on the form 

itself. 

Privacy Act Statement 

Solicitation of this information is authorized by the Federal Employees Retirement law (Chapter 84, 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. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a Social Security Number or tax 

identification number. This is an amendment to title 31, Section 7701. 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 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), OPM Forms Officer (3206-0172), Washington, D.C. 20415-7900. 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. 
Application for Death Benefits 

Federal Employees Retirement System 

Form Approved 

OMB No. 3206-0172

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 (ex. maiden name or his/her middle name) 6. CSA number (if retired) 

7a. Was the deceased applying for or receiving workers' compensation from the Office of 

Workers' Compensation Programs (OWCP), Department of Labor? No Yes 

7b. OWCP claim number 

8. What was deceased person's employment status at the time of death (see pamphlet entitled, Applying for Death

Benefits Under the Federal Employees Retirement System, SF 3114) 

Employee Complete SF 3104B, which can be obtained from 

the deceased person's former employing agency. 

Former 

employee 

Retiree If you are the surviving spouse,

complete SF 3104A (attached) 

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

(mm/dd/yyyy) 

Death Divorce/annulment 

Death 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 

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

Yes No 

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

Widow(er) complete Section C below 

Designated beneficiary (attach copy of designation, if available) 

Parent of decedent (Each parent should complete a separate

application. If one parent is deceased, attach a copy of the death

certificate.) 

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

Former spouse Complete Section D on page 2 

Child (or as guardian of minor or disabled child) 

Other (specify):

6. Did you cash any check(s) issued to the deceased or did you withdraw funds paid by direct

deposit from the deceased's savings or checking account after the date of death? 

No 

Yes 

Section C - Information About the Deceased Person's Spouse 

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

1. Marriage performed by 

Clergy/Justice of the Peace Other (explain) 

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

3. Have you remarried after your spouse died? 

Yes No 

4a. Have you ever applied for a survivor annuity based on the Federal service of a

deceased spouse other than the one named above in Section A.1? 

No Go to item 5 below 

Yes Complete items 4b-4e below 

4b. Name of deceased former spouse 4c. Date of birth (mm/dd/yyyy) 

4d. Name of retirement system (e.g. Civil Service, Foreign Service) 4e. Claim number (assigned to you

by retirement system in item 4d.) 

5. If you will be receiving monthly payments, P.L. 104-134 requires that you be paid by direct deposit into a checking or savings account 

if possible. See Section I. 

Page 1 of 4 Standard Form 3104 

Office of Personnel Management

CSRS/FERS Handbook for Personnel 

and Payroll Offices 3104-106 Revised August 2002

NSN 7540-01-249-5573 
Section D - Information About the Deceased Person's Former Spouse

(Complete if you are a former spouse) 

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

2. Is there a court order awarding you any portion of the deceased person's Federal Employees Retirement System (FERS) retirement 

or survivor benefits? Yes, on record at OPM Yes, attached No 

3a. Are you paying for Federal Employees Health Benefits 

coverage to a former employing office? No Go to item 4a Yes Go to item 3b 

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

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

No Go to item 5a Yes Go to item 4b 

4b. Date of first marriage after marriage to deceased ended 

(mm/dd/yyyy)

5a. Have you ever applied for a survivor annuity based on the Federal service of a deceased spouse or former 

spouse other than the one named on page 1, Section A1? No Go to item 6 Yes 

Complete items

5b-5e below 

5b. Name of deceased former spouse (last, first, middle initial) 5c. Date of birth (mm/dd/yyyy) 

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

Service, etc.) 

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

item 5d. 

6. If you will be receiving monthly payments P.L. 104-134 requires that you be paid by direct deposit into a checking or savings account 

if possible. See Section I. 

Special Note: If you checked "Employee" in Section A.8, and your former spouse performed more than 18 months of creditable 

civilian Federal service, and a court awards you all or a portion of the Basic Employee Death Benefit or a survivor annuity, contact 

the deceased person's former employing agency in order to complete the necessary election forms in Standard Form 3104B. 

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

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

Yes Complete items 1b-1f below No Go to Section F 

1b. Name(s) of unmarried dependent

children (list in order of birth) 

1c. Date of birth 

(mm/dd/yyyy) 

1d. Child's relationship to deceased (child 

of former marriage, adopted, etc.) 

1e. Age 18 

or over Student Disabled 

1f. Child's Social 

Security Number 

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

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

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

No Complete items 3b-3d below Yes Go to item 4a 

3b. Name and address of person having responsibility for child 3c. Name(s) of children 3d. Custodian's Relationship to child 

Legal guardian 

Other Specify 

Legal guardian 

Other Specify 

Legal guardian 

Other Specify 

Page 2 of 4 

Standard Form 3104 

Revised August 2002 
deceased? 

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

No (Application required for payment of benefits.) Yes 

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

determinations for each child? No Not yet received (Forward to OPM upon receipt.) Yes 

Section F - Information About Other Heirs 

List other relatives who can inherit from the deceased as explained in the instructions. 

1. Full name of relative 2. Complete address 3. Relationship to deceased 

Section G - Information About the Deceased Person's Estate 

1. Has an executor, administrator or other official been 

appointed by the court to settle the estate of the deceased? 

No Go to item 3 below Yes 

2. Full name and address of person appointed (street, city,

state, ZIP code) 

3. If an executor, administrator or other official has not been court appointed, will one be appointed? Yes No 

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

Complete if deceased was an employee or former employee at time of death. Do not complete if the deceased was retired at the 

time of death, since OPM already has this information. 

1. If the deceased performed active, honorable service in the Armed Forces or other uniformed service as described in the instructions, 

complete items 1a-b below and attach a copy of the discharge certificate or other certificate of active military service (if available). 

a. Branch of service 

b. Dates of active duty 

From (mm/dd/yyyy) To (mm/dd/yyyy) 

2. Complete if deceased was an employee or former employee at time of death. If any of the above listed service was performed after

12/31/56, was a deposit to the Retirement Fund made for the service? 

Yes Don't know No 

If deceased was an employee at the time of death, complete and attach Standard Form 3104B 

which can be obtained from the deceased person's former employing agency. 

3a. All surviving spouses and former spouses complete.

Was the deceased receiving military retired pay at the time of death? Yes No 

3b. Did the deceased ever waive military retired pay? Yes No 

3c. Are you eligible for military survivor benefits? (Attach verification

of your eligibility/ineligibility for such benefits) Yes No 

Section I - Direct Deposit 

1. Public Law 104-134 requires that most Federal payments be paid by Direct Deposit through Electronic Funds Transfer (EFT) into a 

savings or checking account at a financial institution. However, if receiving your payment electronically would cause you a financial 

hardship, or a hardship because you have a disability, or because of a geographic, language or literacy barrier, you may invoke your

legal right to a waiver of the Direct Deposit requirement, and continue to receive your payment by check. Therefore, you must select 

one of the following: 

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

Receiving my payment(s) electronically would cause me a financial hardship, or a hardship because of a disability, or because of a 

geographic, language or literacy barrier. I hereby invoke my legal right to a waiver of the Direct Deposit requirements of Public Law 

104-134. Please send me my payment(s) by check. (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.) 

Page 3 of 4 Standard Form 3104 

Revised August 2002 
Section I - Direct Deposit (Continued) 

2. Do you want to have your survivor annuity payments made to the same checking or savings account to which OPM made 

payments by Direct Deposit to the deceased before his or her death (must be an active account and you must be a owner)? 

Yes No 

3. Do you want your survivor annuity payments made to a checking or savings account to which we have not already been 

making payments by Direct Deposit? Yes No 

4. Financial institution routing number (You may obtain this number by calling your bank, credit union, or savings institution.

This number is very important. We cannot pay by direct deposit without it. We suggest you call your financial institution to 

verify this number.) 

5. Checking or savings account number 6. What kind of account is this? 

Checking Savings 

7. Name and address of your financial institution 

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

Special note: If you prefer, you may attach a cancelled personal check that shows the information requested above, instead of filling in the 

requested financial institution information. If you attach your personal check, it is especially important that you contact your bank, credit 

union, or savings institution to confirm that the information on the check is the correct information for direct deposit. (Some institutions, 

especially credit unions, use different routing numbers on checks.) OPM can use this information to start paying you by direct deposit. 

Section J - Certification 

I hereby certify that all statements made in this application are true to the best of my knowledge and that no evidence relating to the 

settlement of this claim is withheld. I have read and understand all of the information provided in the instructions to this application. 

1. Signature of applicant named in Section B. (sign in ink; do not print.) 3. Daytime tele.# (area code) 

Best time to call you 

4. Date (mm/dd/yyyy) 

2. Mailing address Warning: Any intentionally false or misleading statement or 

response you provide in this application is a violation of the 

law punishable by a fine of not more than $10,000 or 

imprisonment of not more than 5 years or both. (18 USC

1001) 

Section K - Applicant's Checklist 

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

Document Title Requirement Attached 

Yes No N/A Comments

Death certificate Certified copy required in all cases 

Marriage certificate Required if you were spouse of deceased at time of death (if married more 

than once, provide copies of all certificates) 

Child(ren)'s birth

certificate Recommended for all children for whom you are applying for benefits 

Social security award

determinations 

Needed for all minor children and spouse if spouse is under 60 and is 

currently eligible for mother, father or disability benefits from the Social 

Security Administration (SSA), based on deceased person's service. Also 

needed for all children who are unmarried and are age 18 or older, but who became mentally and/or physically disabled before age 18 and who,

because of disability, are incapable of self-support. If not submitted, the 

Office of Personnel Management (OPM) will obtain the information from 

SSA; however, this may delay the processing of your claim. 

Court papers appointing

executor/administrator 

Required if you are applying as executor or administrator of deceased 

person's estate 

Court papers appointing

guardian for minor or 

disabled child(ren) 

Required if you are applying on behalf of minor or disabled children of 

deceased and guardian has been appointed by court. 

DD 214's or other 

military discharge

certificates 

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

information may delay the processing of your claim. 

Page 4 of 4 

Standard Form 3104 

Revised August 2002 
OMB No. 3206-0172 

Form Approved Survivor Supplement 

Federal Employees Retirement System 

Complete this form if deceased was retired at the time of death. Attach this form to the Application for Death

Benefits, SF 3104, before forwarding it to the Office of Personnel Management (OPM). 

To be completed by surviving spouse if he/she is under age 60 and the deceased had at least 5 years of creditable civilian service. 

Identifying Information 

Name of deceased retiree (last, first, middle initial) Date of birth (mm/dd/yyyy) Social Security Number CSA claim number 

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

1. The amount by which the survivor annuity that would have been payable under Civil Service Retirement System (CSRS) rules 

exceeds the basic annuity payable under Federal Employees Retirement System (FERS) rules, or 

2. The amount of a deemed widow/widower's Social Security benefit based on the deceased's service under FERS. 

The deceased retiree must have performed 5 years of service that could be creditable under FERS or CSRS rules, including one full 

calendar year of service creditable under FERS rules. 

You may be eligible for a survivor supplement if you are the surviving spouse of a retiree and you are: 

1. under age 60; and 

2. entitled to Social Security benefits at age 60; and 

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

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

1. Name of surviving spouse (last, first, middle initial) 2. Spouse's date of birth (mm/dd/yyyy) 

3. Are you disabled? 

No Go to item 4 

Yes Go to items 3a and 3b. 

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

retiree's service? 

Yes No Applied, but no response yet Have not applied 

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

Yes No Applied, but no response yet Have not applied 

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

Yes No, I have been denied these 

benefits (attach photocopy of 

denial letter). 

No, I know I do not qualify for these benefits 

as there are no surviving dependent children 

under age 16 or disabled who are entitled to 

SSA child's insurance benefits. 

Applied, but no response yet

Have not applied 

5. If you are not currently receiving Social Security mother, father or disability benefits, do you agree to notify us promptly if 

you are later awarded any of these benefits? 

Yes No 

6. Signature 7. Date (mm/dd/yyyy) 8. Telephone number (including area code) 

Office of Personnel Management

CSRS/FERS Handbook for Personnel 

and Payroll Offices 

Standard Form 3104A 

Revised August 2002