CLAIM FOR UNPAID COMPENSATION OF DECEASEO MEMBER OF THE UNIFORMED SERVICES 

General lnforn to all claimants by 

the employing c oyed at time of Example: Designated Beneficiary (Not Estate or Trust) death. 

-=p=-a-rt--::A:-.--------------- · - ·- - ­

1. Name(sl and social security 

number(s) ol claimant(s) 

John J. Smith Jr. 

123-45-6789 

2. Relationship to deceased 

Son 

3. II minor, state age 

N/A 

4, Is designation of beneficiary for unpaid 

compensation on file with service? Yes -­- (Yes or No) 

5. Are you named beneficiary? Yes 

(Yes or No) 

6. Claimant(sl State of Legal Residence 

Ohio 

7. Name, rank or rating, .servic·e number, and 

social security number of decedent 

MSGT John J. Smith Sr USMC 

987-65-4321 

e. Date of Death 

6/30/2010 

9. Name of Service 

u s "-' c.. 

10. Decedent's domicile 

California 

Part B (To be completed by the widow or widower of the deceased only.) Do you certify that you were married to the decedent 

and to the best of your knowledge and belief that the marriage was not dissolved prior to his/her death? 

WIDOW OR WIDOWER AND DESIGNATED BENEFICIARIES DO NOT FILL IN PART C. All OTHERS MUST. 

Part C 

1. List below the name, social security number, age, relationship, and address of: 

(a) Widow or widower. 

(b) If no widow or widower survives, list each living child of the deceased (include natural, adopted, illegitimate, and stepchildren 

and indicate after their names which class) or the descendants of deceased children. 

(c) If no widow or widower, child or descendant of deceased children survives, list each surviving parent and state whether 

natural, step, foster, or adoptive parent. 

(d) If none of the above survives, list the next of kin who may be capable of inheriting from the deceased (brothers, sisters, 

descendants of deceased brothers and sisters). 

Name and Social Security Number Age Relationship to

Deceased Address

Standard Form 1174 (EG} 


September 1992 


4 GAO 26. 1 


(This form has been authorized for local reproduction.) 


(Continued on other sode) 
-------------------------------

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SF 1174 (Back) 

Part D 

- 1. If none of the above survives and an executor or administrator has been appointed, the following statement should be completed: 

1/we have been duly appointed N/A of the estate of the deceased, as evidenced by 

(Executor or administrator} 

certificate of appointment herewith, administration having been taken out in the interest of 

(Name, address, and relationship of interested relative or creditor) 

and such appointment is still in full force and effect. 

NOTE.-- If making claim as the executor or administrator of the estate of the deceased, no w itnesses are required, but a court certificate evidencing your appointment 

must be submitted. 

2. 	If no administrate( or executor has been appointed, will one be appointed? N/A 

(Yes or No) 

DESIGNATED BENEFICIARY, SURVIVING SPOUSE, CHILDREN, PARENTS, OR LEGAL REPRESENTATIVES DO NOT 


FILL IN PART E. ALL OTHER MUST. 


PartE 

Have the funeral expenses been paid? ____N_I_A_____ {If paid, receipted bill of the undertaker must be attached hereto.) 

(Yes or No} 

Whose money was used to pay the funeral expenses? N/A 

FINES, PENAL TIES, and FORFBTURES are imposed by la.w for the making of false or fraudulent 

claims against the United States or the making of false statements in connection therewith. 

6/30/lO 

(Signature of claimant} (Date} 	 (Signature of claimant} IDa tel 

123 Main St. Apt B 

(Street address} 	 !Street address} 

Capitol, OH 44444 Phone (555) 555-5555 

(City, State, and ZIP code} 	 (City, State, and ZIP code) 

TWO WITNESSES ARE REQUIRED 

We certify that we are well acquainted with the above ____________J_o_hn_J_S_n_li_th_Jr_.___________ and t hat 

(Name(sl of claimant(s}) t he signature(s) of the claimant(s) was (were) affixed in our presence. 

tAU~ vJI\~itJ<; 

/{Sign

David Watkins --- Barb Johnson 

ature of w itness} 	 (Signature of witness} 

123 Main St Apt C 	 123 Main St Apt D 

!Street address} 	 (Street address} 

Capitol, OH 44444 	 Capitol, OH 44444 

(City, State, and ZIP code} 	 (City, State, and ZIP code} 

All Federal checks in possession of the claimant, drawn to the order of the decedent, in payment of pay and allowances should accompany this claim.